Inspection on 04/10/05 for Swallows, The

This inspection was carried out on 4th October 2005.

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

The inspector 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, The 11/07/07

Swallows, The 18/05/06

Swallows, The 28/04/05

Swallows, The 02/09/04

Swallows, The 11/05/04

Similar services:

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Swallows, The 318 Brownhill Road Catford London SE6 1AX Lead Inspector Sean Healy Unannounced Inspection 4th October 2005 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, The DS0000025645.V258088.R01.S.doc Version 5.0 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, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Swallows, The Address 318 Brownhill Road Catford London SE6 1AX 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) 0208 4613391 020 8461 1200 Mr Alan Wilde Mrs Susan Wilde Mrs Susan Wilde Care Home 19 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (19) of places Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 19 elderly persons of whom up to 12 may have dementia 28th April 2005 Date of last inspection Brief Description of the Service: The Swallows is a private care home managed by the proprietors since opening in 1984. It is a large Victorian house situated between Lee and Catford, within walking distance of shops and public transport. It is registered for older people and people with dementia. The home is no longer registered for those who are physically disabled. The home has 13 single rooms and 3 shared rooms. It is centrally heated and attractively decorated. Washing facilities are available in all bedrooms and there is a 24-hour nurse call system. There are two lounges, dining areas and a conservatory. There is a garden with a patio area for use in good weather. Service users are encouraged to bring in personal items of furniture and mementos to personalise their bedrooms. Bathrooms and toilets have aids and adaptations available. Visitors can be entertained in all of the communal areas and in private bedrooms. There were no vacancies at the time of inspection. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out in one day on the 4th October 2005. The registered manager and provider were present and took part in the inspection process. The inspector interviewed three staff individually and met informally with a group of 6 service users over lunch. The inspector met individually with two service users. Comments from all are included in this report. The inspection included a tour of the home and examination of records on care plans, staff records and building maintenance records. During the inspection staff interaction with service users was observed to be regular and conducted in a respectful manner. What the service does well: What has improved since the last inspection? The home has done a lot of work to ensure that all service users understand the terms and conditions for living at the home. The system for deciding on what food goes on the menu has been looked at to ensure that service users’ personal tastes are included and a number of service users said: “The food is very good and I am asked what I would like to eat”. A number of staff have gone on training about Adult Protection to better understand how to protect service users, and three staff have done induction training. A handrail has been installed to help service users who need it to enter the house. The manager and staff have begun getting better information on service users’ life histories and in planning activities on a more individual basis. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 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. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 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, The DS0000025645.V258088.R01.S.doc Version 5.0 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 and 5 The home’s Statement of Purpose is not complete and does not fully ensure that prospective service users are making an informed choice about where they live. Service users are fully informed regarding contractual terms and conditions. Prospective service users have good opportunities to visit the home and assess the quality of care provision before being admitted. EVIDENCE: The home’s Statement of purpose and Service User Guide have been given to service users. The home’s manager and service users confirmed this and copies are available on file. While advocacy support is promoted in the home on a notice board not all service users are aware of this and there is no reference to it in the complaints policy. Some service users expressed that having someone help them to speak up is important as they may not feel confident to do so themselves. The Statement of Purpose contains some detail of staff experience but does not yet include a reference to NVQ training staff have achieved. The manager agreed that this omission would be addressed. Any additional charges such as the cost of hospital visits should also be included. (Refer to Repeated Requirement OP1) Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 9 The majority of service users are funded by the local authority with about one third of service users being privately funded. The manager has now provided information for all service users regarding their terms and conditions for staying at the home, and is finalising production of written confirmation of this for a few service users. The home’s policy for service users visiting to assess whether the home is suitable for their needs, including a stay-over if requested, and one service user confirmed that she had found the home gave her good information before she decided to move in and that this information was correct. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 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 and 8 The home ensures that service users health, personal and social care needs are set out in an individual care plan and that health care needs are fully met. EVIDENCE: Each service user has an individual care plan, which is reviewed monthly by a key-worker, and more acute issues such as pressure sores are reviewed weekly by the manager. The “Standex” system is used for planning for health care and this is now supported by a separate system for planning for each service user’s leisure and social care needs. A system has been introduced for recording service users participation in leisure activities. Risk assessments on six service users files were good and comprehensive. There was evidence of monthly reviews taking place consistently but there was not enough room on the charts to record the full extent of these reviews. The home should introduce a system for recording the monthly reviews more comprehensively and should provide improved guidance for staff for areas of support where risk is assessed as high. (Refer to Recommendations OP 7) The home has excellent systems, equipment, training and practices in place for supporting all service users health care needs. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Service users find that lifestyle experiences in the home matches their expectations and preferences, including social, cultural, religious and recreational interests. Service users receive a wholesome and balanced diet in pleasant surroundings and their personal tastes are included on menus offered. EVIDENCE: There is evidence of a good assessment process, which is transferred into support plans for each service user. A range of activities within the home is offered to service users. There is a monthly menu setting system in place which service users are consulted on and service users confirmed this in discussion at dinner. There is now a detailed weekly social and leisure activities plan in place for each service user, and a record is kept to ensure activities are offered consistently. There has been improvement in the information available about people’s life histories, which help to inform the plans, and ensure that plans are relevant to individual service users. There is ongoing work in improving these plans for all service users. Staff have been engaging in discussion with service users and their families to compile information. It is recommended that the manager monitor this process until completion. (Refer to Repeated Recommendation OP12) Service users have confirmed that they are involved in deciding what food is being offered on the menu, and have a choice of nutritious food offered to Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 12 them. Menus are being kept and there is due consideration of special dietary needs. A number of service users said: “The food is excellent”. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home’s policy and practices do ensure that service users are protected from abuse. EVIDENCE: There is an Adult Protection policy and Whistle Blowing policy, which are made available to service users and their representatives from admission, and is written in a manner understandable to the majority of service users. The home has now increased the number of staff having specific training on Adult Protection by five staff with all other staff scheduled to attend over the coming months. A form is now in place for staff to check and record recognised areas of abuse and there was evidence of this issue being discussed with staff at team meetings. Two staff interviewed showed good understanding of the policy for reporting suspicion of abuse and were careful not to carry out investigations without having reported to management immediately. The home’s owner and manager are constantly available at the home and service users said: “I trust the manager and have known her for a long time.” Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23, 24, 25 and 26 The home’s location and layout generally meet the assessed needs of the service users and is well maintained, comfortable, hygienic and safe. However, there are not sufficient shower room facilities, which limits service users’ opportunities in maximising independence in personal care. The home overall, and service users’ own rooms, suit their needs and are personalised, safe, hygienic and comfortable. EVIDENCE: The home is located in a residential street within walking distance of shops and public transport. The co-proprietor of the home is responsible for routine maintenance in the home, which is generally well decorated and maintained. The home benefits from a lift to allow access to floors above ground level. The garden is well maintained and fully accessible. The home has sought guidance from the local Fire Authority as to the suitability of the building and has complied with all requirements. There is a CCTV monitor in the staff office that the registered person confirmed was only used to monitor exits for security reasons. There are a number of magnetic door closure mechanisms within the Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 15 home. Records of fire equipment checks were examined and found to be in good order. An Occupational Therapist assessment report states that there is a need for the home to have additional shower room facilities to meet the needs of the nineteen service users. Currently there are two bathrooms and no shower room facilities, which, falls short of best practice recommendations. The registered provider is trying to address this issue but has not yet managed to agree contract terms for the coming few years with the local authority. There are specific areas regarding the provision of shared rooms which need agreement before the home can commit to carrying out work on shower rooms as recommended. There is evidence that the manager has been trying to resolve this issue. This requirement is repeated with a revised timescale for completion. (Refer to Repeated Requirement OP 22) Of the home’s nineteen residents, thirteen have single rooms and six residents share three rooms. All rooms are adequate in the provision of facilities such as sinks and furniture but the number of single rooms falls short of the recommended target of 80 . (Refer to Repeated Recommendation OP 23) The home provides each service user with clean comfortable bedrooms, which are well maintained and furnished. Rooms are well ventilated heated with good natural and electric lighting. The manager has had difficulty in finding a suitable alternative to the current waste disposal bin being used in the bathroom. The manager should continue to try to find an alternative to ensure that all service users are safe from access to disposable continence waste materials. (Refer to Recommendation OP26) Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 30 Staff are experienced in the care of the elderly and are of sufficient numbers and abilities to meet service users’ needs. However, the home cannot yet demonstrate that staff are fully trained and competent to do their jobs, which may result in inconsistent quality of care. EVIDENCE: The home employs seventeen full time staff, none of whom are nursing staff, which is appropriate for this home. There are four staff on duty up to 5pm and three staff between 5pm and 8pm after which there are two waking staff for night care support. There is a cook employed to for 7 days a week, and cleaning is done on a contract basis, allowing care staff to be available for care and support duties. There is a clear rota showing who should be on shift at any one time and service users said that they know the staff well. There is minimal sickness and little use of agency staff. Four staff have completed NVQ level two and two other staff are half way through completing this course. Three other staff are starting this course in November 2005. There is good commitment shown to increasing the numbers trained staff, but numbers do not yet meet the required 50 target. (Refer to Repeated Requirement OP28) The homes induction for new staff is now comprehensive, and is in line with the TOPPS certified training programme. The manager confirmed that she has begun work on changing the induction training process and three staff have Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 17 been inducted in accordance with the new system, and other staff are being inducted in this manner. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33, 35 and 38 The home is being well managed by a manager of good character and experience; however, the manager has not yet completed required NVQ training, which may affect her abilities to demonstrate fully her competence in managing this service. Although the home consults with service users it does not yet demonstrate that planned developments are based on service users’ views and interests, which may exclude service users from important decisions regarding quality improvements. Service users’ financial interests are safeguarded and the health, safety and welfare of service users are promoted and protected. EVIDENCE: Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 19 The registered manager holds a nursing qualification and is currently undertaking the NVQ Level 4 Registered Managers Award. She has completed three modules on Leading Meetings, Management and Performance of Teams and Individuals and Developing/Enhancing Teams and Individuals’ Performance. The registered manager has been managing this home for approximately 20 years, since it opened. The manager confirmed that she has not yet completed this NVQ level 4 course. (Refer to Repeated Requirement OP31) The home conducts service user surveys twice a year, and copies of responses are placed in the homes “notice folder” which is accessible to all service users and families. The home also facilities service user meetings every three months. Complaints logging system also provides some information on service users concerns, which the manager does review and act on. However, the home does not conduct annual quality audits and does not yet produce an annual development plan from the information received. (Refer to Requirements OP33) The home has very good practices in place for safeguarding and recording service users personal finances. All service users have a lockable space in their rooms for keeping their valuables safe but all except two service users have decided to ask the home to look after their personal money. Service users have been appropriately consulted on this issue. The home makes every effort to ensure service users are safe and that the home is well maintained. There are policies on health and safety, and regular training for staff in al related areas such as fire safety, moving and handling, risk assessments, food hygiene and first aid. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X 2 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 21 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(1) c 22(1) Requirement The registered manager and provider must ensure that the homes Statement of Purpose is updated to advise service users of their right to advocacy when using the complaints and compliments policy procedure, and to include details of care staff NVQ qualifications. This is a repeat of previous requirement Timescale 31/08/05. The registered provider must ensure that a strategy is put in place to action the Occupational Therapist assessment report recommendations regarding the provision of additional shower room facilities. The strategy must detail the work to be done and the timescale for completion. A copy of this plan must be forwarded to the Commission for Social Care inspection. This is a repeat of previous requirement Timescale 31/10/05 now extended. The registered provider and manager must ensure that a DS0000025645.V258088.R01.S.doc Timescale for action 30/11/05 2 OP22 23 (2) j 31/01/06 3 OP28 18© (i) & (ii) 31/12/05 Page 22 Swallows, The Version 5.0 4 OP31 9(2)b (i) 5 OP33 24 (1,2 and 3) 6 OP33 24 (1,2, and 3) minimum of 50 of care staff attain NVQ level 2. This is a repeat of previous requirement, Timescale 31/12/05 still ongoing. The registered manager must adhere to Sector Skills Council requirements and complete NVQ level 4 in management and care. This is a repeat of previous requirement, Timescale 28/02/06 still ongoing. The registered provider and manager must ensure that there is an Annual Development Plan for the home based on a systematic cycle of planning, action and review. The registered provider and manager must ensure that a quality audit is conducted at least annually 28/02/06 28/02/06 28/02/06 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 3 Refer to Standard OP7 OP7 OP12 Good Practice Recommendations The registered manager should introduce a system for recording the monthly review of service users’ plans and any action taken The registered manager should provide written guidance for staff where service users’ risk assessments have shown high levels of risk in the first instance The registered manager should continue the development of more expansive individual histories and backgrounds about each service user, with the involvement of the service user and their representatives, as an aid to reminiscence activities. This information should be made available to support staff only with the permission of the service users. This recommendation is repeated from last inspection. DS0000025645.V258088.R01.S.doc Version 5.0 Page 23 Swallows, The 4 OP23 5 OP26 The registered provider should begin now to consider how the home can offer at least 80 of its places in single rooms by April 2007. Details of this financial planning should be included in the business plan for the home. This recommendation is repeated from last inspection. The registered manager should ensure that all service users will not try to access used soiled materials in the current system of storage, or provide alternative means of storage. Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Swallows, The DS0000025645.V258088.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!