Inspection on 19/01/09 for Swallows Residential Home

This inspection was carried out on 19th January 2009.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Swallows Residential Home 30/06/09

Swallows Residential Home 05/09/08

Swallows Residential Home 15/05/08

Swallows Residential Home 12/06/07

Swallows Residential Home 30/10/06

Swallows Residential Home 15/05/06

Swallows Residential Home 28/02/06

Swallows Residential Home 29/11/05

Swallows Residential Home 05/09/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Swallows Residential Home Helions Bumpstead Road Haverhill Suffolk CB9 7AA Lead Inspector Mrs Jan Sheppard Key Unannounced Inspection 19th January 2009 10:00 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 Swallows Residential Home DS0000063929.V373809.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. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swallows Residential Home Address Helions Bumpstead Road Haverhill Suffolk CB9 7AA 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) 01440 714745 01440 761315 Burrows Care Homes Miss Ann Marie Burrows, Mr Harold Burrows, Mrs Donna Burrows Manager post vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Swallows Residential Home offers care and accommodation for up to sixteen older people, in single storey accommodation situated on the outskirts of the town of Haverhill in a rural position. The home was first registered in 1995 and the building adapted to provide appropriate accommodation for seven residents. In February 2000 an extension was completed, providing good quality and pleasant additional communal and bedroom accommodation and increasing the registration of the home to fifteen. In November 2000 a previous office was converted into an additional resident bedroom and the total increased to sixteen residents. All resident bedrooms are for single occupancy with one room having an en-suite toilet facility. The home came under new ownership and management in June 2005. The owners who are three family members who trade as Burrows Care Homes are the registered persons. The manager’s post became vacant in March 2008 when one of the registered persons took over as manager. The fees range between £331.00 and £375.00 per week. The cost of newspapers, chiropody, hairdressing and some transport is not included in the fees. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 *. This means that people who use the service experience poor quality outcomes. This key inspection was conducted during a weekday when two inspectors spent a total of twelve hours in the home. The assistant Manager Tracey Robb who was in charge of the home was present throughout and she along with all other members of staff on duty gave their full help and assistance with this inspection. During this inspection a tour of the building was made, in depth discussions were had with the assistant Manager and staff on duty and all the residents were spoken with. A number of visitors to the home were also met and spoken with. Spot checks were made on a number of the home’s records. The detail in this report reflects the findings on that day and also takes account of periodic information sent to the Commission by the homes Manager and information given by the Pharmacist in the report of his Random visit to the home on 18th December 2008. What the service does well: What has improved since the last inspection? Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 6 The requirements made at the last inspection concerning the storage and administration of medication have been met. The detail in the care plans have improved and the layout of these documents has been standardised. A programme of staff supervision has been set up and staff said that they were finding these meetings helpful. The home has revised its Safeguarding Policy and Procedures for staff guidance based on the guidelines set out in the Suffolk Interagency procedures. Further staff training for this must be arranged. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Swallows Residential Home DS0000063929.V373809.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 Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply as the home does not accept referrals for intermediate care. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Not all the people who use this service can expect to receive an assessment of their care needs prior to their admission to the home. EVIDENCE: The home has good policies and procedures for the assessment of the care needs of prospective service users who are referred to the home in the normal manner for long term placement. The Manager visits each prospective applicant in their home or other setting and gives them and their families good Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 9 information about the service so that the can decide if it will meet their needs . They are invited to visit and test the home before making any decision about admission. At the last inspection it was seen that this process was being followed and a good quality for these standards was being achieved. However at this inspection the records relating to number of residents who had been referred to the home for short stays or where the admission was requested at short notice in an unplanned manner then a full pre admission assessment had not been carried out an omission which could leave the resident at risk. Whilst the homes subsequent records did show that the staff had worked very hard in assessing needs and compiling a care plan as soon as possible upon admission it was also evident in talking with residents and staff that problems did still arise. One resident arrived at the home without all their mobility equipment and another who was moving into the area prior arrangements had not been made for them to have cover from a new GP both these problems posing potential risk and in the case of interrupted medication even danger for the resident. The home must ensure that they have the capacity to make immediate assessments of care need where urgent or emergency admissions are being considered this to fully protect the resident. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to receive planned care to meet their assessed needs and that this will be delivered in a responsive and dignified manner. The homes medication practices offer an adequate level of protection to people living in the home although there is room for further improvement with these practices. EVIDENCE: The care plans examined were all found to be well recorded with adequate detail and to be following the new format recently introduced in the home. The plans are divided into subject sections so that the various areas can be easily Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 11 identified and accessed and needs more clearly identified. Reviews of these plans were seen to be recorded although there did not appear to be a consistent pattern for these some were recorded monthly others weekly or even daily and there was not sufficient explanation for this variation. Doctors and Nurses visits to the residents were seen to be recorded and at this inspection better evidence could be found that any instructions given had been fully implemented. The daily records were well recorded although some discrepancies (dates of visits from the nurse) between the information given in these records and that found in the care plan reviews were found. The changing care needs of one resident who had recently been discharged from hospital were seen to be well recorded including information shown visually on a body chart. A Doctor who visited this resident during the time of this inspection said that the home was ‘doing well’ managing her changing care needs. No evidence could be found that the home had reassessed this residents care needs and abilities whilst she was still in hospital before she was discharged back to the home. People who use this service all have a named key worker and during this inspection all the residents spoke positively about the care and assistance they receive from the staff. One told the inspector ‘as this is a small home the carers get to know us well it’s a bit like a big family and I feel well looked after’. Staff were seen to be knocking on bedroom doors before entering and were heard to be offering residents choices in a respectful and dignified manner. Records of all the resident’s weights are regularly recorded. Three were noted to be of low weight and their care plans evidenced what actions were being taken to boost their nutritional intake. The cook had a good awareness of these residents and was able to speak of the individual measures that she had taken in consultation with the resident to help them improve their food intake and to ensure that this was of a high nutritional content. The records evidenced that the doctor was consulted about weight changes and special nutritional drinks where prescribed were given to the resident. All the residents spoken with said that they were happy with the food and with the choices available to them although one resident did say that she would prefer to be in her own home with her own kitchen where she could cook for herself. The residents explained that the cook consults with them daily about the menu choices. One resident told the inspector ‘the cook always asks me about the daily menu and will make me something different if I ask for it. Because of my eating problem she will make something lighter or softer that I can manage’. The cook reported that one resident had chosen to have her food liquidised and that she liked all the constituents of the meal to be mixed together. The cook said that as this was not considered to be good practice her doctor and family had been consulted but as it was her clear wish the practice Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 12 continues. The cook said that she noticed that this resident is now consuming much more than she had been previously. Since the last inspection (5/9/08) which was carried out jointly with the Pharmacist he had made a return visit to the home (18/12/08) and had found that appropriate actions had been taken to meet the medication requirements made at that time. The home continues to use a monitored dosage system to manage its medication and two members of staff are undertaking the Safe Handling of Medications training course at West Suffolk College. At this visit the medication was found to be properly stored with opening dates recorded. The MAR (medication administration record), sheets were seen to be accurately recorded with any variations properly noted by the code letter and by written explanation on the reverse of the sheet. Part of the lunch time medication round was observed and it was noted that the member of staff gave sufficient time to each resident whilst administering their medication. However it was seen that they did not consistently complete the administration record sheet after having administered the medication and on two occasions when she was called away from this task to take a telephone call the medication cupboard door was closed but was not locked and neither were the keys removed. To ensure full safety for the residents it is recommended that whilst administering medication the member of staff is not interrupted and that management arrangements are put in place to ensure that they can focus solely on that task for that limited period of time this to ensure full safety for the residents. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. People who use this 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 this service can expect to be provided with a range of activities to meet their various choices. People who use this service can be confident that they will be offered choices from a varied diet of nutritious home cooked food. EVIDENCE: There have been no major changes to the manner in which the services in this section are delivered since the last inspection in September 2008. The home continues to provide daily activities which the residents can choose to participate in or not. The plan of activities for January was seen to be displayed in the lounge. Residents spoken with even those who chose to spend most of their time alone in their bedrooms were all aware of when the various activities were held and said that they would join in if they wished. One said Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 14 ‘the staff normally come along and say that the bingo or the craft class is about to start and help me if I decide to go to join in’. Several residents told the inspector that they enjoyed the external entertainers who regularly visit the home. One resident who was knitting said that often staff would assist her and other residents join in with this activity. The hairdresser visited the home during this inspection and many residents were seen to join in with those who were having their hair done in what was clearly a regular social occasion. Only one resident complained that the activities provided did not really suit them so they chose not to participate. The kitchen was visited and the cook spoken with as part of this inspection. She is an experienced cook who had previously worked for many years as a chef working in a commercial setting. She confirmed that since the last inspection she had completed a Food Hygiene training course at a local college. She had good awareness of the systems associated with the Safer Food Better Business procedures issued by the Food Standards Agency and had been judged to be following these correctly at a recent inspection from the Environmental Health Agency on 7/1/09. The kitchen was found to be clean tidy and well organised and it was seen that the temperatures of fridges and freezers are regularly recorded. It is required that the recently torn fly screens on the kitchen window are replaced so that proper protection is given against any fly infestation and flaking paint on the window sill needs to be repaired so as to provide an impervious surface. At the beginning of the morning of this inspection the cook was seen to speak with the residents sitting in the lounge and then to visit each of the other residents in their rooms to take them a cup of coffee and to discuss their menu choices individually. The menus evidenced that good choices are available and that fresh vegetables home baked cakes and puddings are prepared each day. The serving of lunch was observed and it was seen that staff offered help to residents that needed this in a discrete manner and that the lunch was a relaxed occasion. All the residents commented favourably on the food and this comment was echoed by relatives consulted with. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can be confident that the policies and procedures in place will ensure that their concerns and complaints are listened to and investigated. However they cannot be assured that all staff have sufficient knowledge and understanding to fully safer guard service users. EVIDENCE: The complaints policy was on display in the home and is accessible for residents and relatives. Residents and relatives spoken with during this inspection all confirmed that they would know what to do if they had reason to make a complaint. During this inspection one resident who was observed to visit the office to raise a concern was seen to be treated patiently and given time to explain her concern. The home had not received any complaints since the last inspection. Other agencies had received anonymous complaints and the subject of these had been followed up by inspection. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 16 Since the last inspection the home has reviewed its policy and procedures on Adult protection and Whistle Blowing and staff had been made aware of these revisions. Staff spoken with during this inspection had an understanding of the variations of abuse and the purpose of the whistle blowing procedures but not all had such a clear understanding or could fully evidence their knowledge of the key steps necessary in a safeguarding situation and what the expectations of their role would be. To ensure that all staff fully understand and are comfortable with the process of reporting any suspicions that they may have refresher Safeguarding training for all grades of staff should be arranged. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 ,25 and 26 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service will find that it is homely well appointed comfortable and clean. However they cannot be assured that some unsafe aspects of the environment will not leave them at risk. EVIDENCE: A tour of the building was undertaken as part of this inspection and it was found to be clean tidy and to have no unpleasant odours. Residents bedrooms were well personalised in a homely manner which reflected their individual tastes and styles. The residents spoken with (all except one) said that they were happy with their bedrooms and that they had the furnishings and Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 18 equipment (special cushions mattresses and reclining chairs) that met their needs. One resident complained about the quality of the curtains and said that the window was very draughty. Another resident said ‘they (the staff) come in regularly to clean and tidy my room and help me rearrange my things if I ask my room is always fresh and nice’. Staff confirmed that each bedroom has a lockable storage space but not all relatives visiting during this inspection were aware of this. Call bells were seen to be available in all the bedrooms and where needed these had extended leads so that the bell was accessible from all points of the room. Residents confirmed that a bell call was usually answered promptly. There have been no changes to the laundry arrangements since the last inspection when this aspect of the service was found to be satisfactory. Service users asked were complimentary about the standard of their laundry and on the day of this inspection they were seen to be well dressed with freshly ironed clothing. Staff consulted were able to evidence a good awareness of infection control measures gloves were seen to be used and some staff were seen to be carrying and using individual hand wash. At the last inspection many of the radiators around the home were found to be without low surface temperature heat covers which must be provided to ensure that the service users live in a safe environment. A requirement was made that to ensure the safety of all service users all radiators must be risk assessed and where a high risk is identified low surface temperature covers must be fitted for protection. At this inspection it was noted that a number of additional low surface temperature covers had been fitted but several radiators in locations which could leave service users at risk remained uncovered and no risk assessments to support this position could be found. The requirement is repeated. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. People who use this service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to be cared for by staff who have had some training and who have been adequately recruited. EVIDENCE: On the day of this unannounced inspection the number of staff found to be on duty matched the numbers stated on the duty rota and were seen to be adequate to meet the needs of the residents at that time and to ensure the smooth running of the home. However the planned duty rota for the rest of that week did not evidence that similar sufficient staffing levels would be available on each day gaps in both management and care numbers were seen. The rota evidenced that the Manager would be on duty in the home for only two days that week and alternative management arrangements on a daily basis were not stated. The assistant manager who was in charge of the home on the day of this inspection explained that the deputy Manager had only just left and that other alternative management arrangements had not yet been put in place although she did say that carer interviews were to be held later in the week. Since the last inspection a number of staff of all grades have left Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 20 their employment some by their own decision and others having been dismissed. The home must ensure that there are sufficient numbers of staff to meet the service users needs at all times. At the last inspection the homes recruitment policy and procedures was found to be robust thereby offering the residents protection. The Assistant manager said that no new staff had been appointed since the last inspection. Staff consulted said that the continued to have good training opportunities and the homes training records evidenced that courses on First Aid, Manual Handling, Deprivation of Liberty, The Mental Capacity Act and the Safe Handling of Medication were planned during January and February 2009. The Assistant Manager is currently with another staff member part way through Medication training at West Suffolk College and she said that when this course is completed she intends to resume her NVQ level3 studies having already completed part of this programme. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 37 and 38. People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the homes manager has been proactive in meeting the requirements made at the last inspection ongoing management shortfalls continue to put the safety and welfare of the service users at risk. EVIDENCE: Since the last inspection the Proprietor managing the home who took over that role in March 2008 has made application to the Commission for Registration as Manager. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 22 On the day of this unannounced inspection the homes management team consisted of herself and an Assistant Manager, the Deputy manager having recently left her post. The recorded staff rota for the week period during which this unannounced inspection fell did not evidence that a manager was to be on duty and in charge of the home on every day .The rota stated that the Manager was to be present in the home for only two days (Wednesday and Thursday ) out of seven which did not provide evidence that she was in day to day control of the home or that she could from a considerable distance discharge her responsibilities fully. The homes records evidenced that since the last inspection a formal planned system for regular staff supervision had been established. Staff spoken with said that they were well supported by the homes managers and found their regular consultation meetings helpful. However staff spoken did not have any records of these meetings and were not aware if any records had been made. Spot checks were made on a number of the homes records including hot water temperature monitoring and the procedures for and frequency of fire alarm checks. The homes makes regular two weekly checks on the temperature of the hot water and these records evidenced that temperatures were largely maintained within the safe limits not exceeding 43 degrees. However checks made by the inspectors on the day of this inspection found temperatures far exceeding this which left the residents at risk. The temperature in the basins in residents bedrooms were found to range up to 67 degrees. In room13 the reading was 66 degrees, in room 14 it was 67 degrees, in room 15 64 degrees was recorded. In rooms 8 and 9 the basin water temperature was found to be 54 degrees and in room 10 66 degrees was reached. An immediate requirement was made and the assistant manager agreed to alert all staff and residents to this potential danger. The Manager has subsequently informed the Commission that individual thermostatic valves are to be fitted to each basin. The records seen evidenced that the home carries out weekly fire alarm bell testing at random locations but no evidence could be found that any fire drills had been carried out. The home has an annual Fire Risk Assessment carried out by an independent company and this was last conducted on 11th September 2008. A number of requirements made in their report following that inspection had not been acted upon. These included the recommendation that fire drills should be carried out at least twice a year, the removal of the signed fire exit notice through the laundry room and the linking of two fire door guards to the central alarm system or that their use should cease, had not been complied with. Whilst fire notices seen around the home which were new since the last inspection did evidence that the manager had taken steps to meet some of the recommendations made not all had been complied with this leaving ongoing risk for the residents and staff. The manager must ensure that Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 23 vulnerable people using this service are not being placed at undue risk and that all necessary actions are taken to remove avoidable risks. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 24 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 x x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 1 x x x x x 1 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 2 x x 2 2 1 Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 25 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 OP19 Standard Regulation 23 (2) (b) (d) Requirement To ensure full infection control and safety is maintained in the kitchen the torn window fly screens and the flaky paintwork on the window sill must be repaired. Regular recorded checks of all hot water outlets must be undertaken and any action taken to remedy excessive temperature must be recorded. Hot water must be maintained within safe limits (not exceeding 43 degrees) this to ensure that vulnerable people using this service are not being exposed to undue risk of scalding. 28/02/09 Timescale for action 28/02/09 2 OP38 13 (4) (a) 3 OP19 13 (4) (a) Medication cupboards must be kept locked at all times and medication administration sheets should not be signed until medication has actually been administered. 01/02/09 Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 26 4 OP3 14 (1) (a) All prospective new service users 01/02/09 must have an assessment of their care needs before being admitted to the home even when admissions are arranged at short notice, this to ensure that their needs can be fully met in the home and their safety ensured. To ensure that fire safety measures give full protection to the service users at all times regular evacuations must be carried out and the requirements made in the fire company’s last report fully implemented. 31/03/09 5 OP38 23 (4) (c) 6 OP19 13 (4) (a) To ensure the full safety of all service users radiators must be risk assessed and where a high risk is identified they must be protected by low surface temperature covers. THIS IS A REPEAT REQUIREMENT 28/02/09 7 OP31 10(1) The Registered owners must 02/03/09 provide to the CSCI a copy of the current job description for the Manager and state their clear expectation as to the role, duties and number of working hours per week actually worked in the home to be undertaken by the Manager. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations Care must be taken that the recording of events and dates on the care plans are consistently maintained. The written records of staff supervision meetings should be maintained by the home and a copy given to the staff member. To ensure that the staff including management are fully aware of safeguarding and whistle blowing procedures refresher training should be arranged for all staff. 2 OP36 3. OP18 4 OP9 To ensure full safety for the residents it is recommended that when administering medication the member of staff is not interrupted and that management arrangements are in place to ensure that they can focus solely on that task for that limited period of time. Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Swallows Residential Home DS0000063929.V373809.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!