Inspection on 20/06/05 for Swan Hill House

This inspection was carried out on 20th June 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

Swan Hill House 11/07/07

Swan Hill House 18/07/06

Swan Hill House 19/12/05

Swan Hill House 21/09/04

Swan Hill House 11/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE SWAN HILL HOUSE SWAN HILL SHREWSBURY SHROPSHIRE SY1 1NQ Lead Inspector TERRY WOODS 20 TH Announced JUNE 2005 09.30 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 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. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service SWAN HILL HOUSE Address SWAN HILL SHREWSBURY SHROPSHIRE SY1 1NQ 01743 360803 01743 344351 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MRS CAROL DAKER CARE HOME 28 Category(ies) of 27 OLD AGE registration, with number 1 PHYSICAL DISABILITY of places SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 28 service users. 2. The home may accommodate 27 older persons and one person with a physical disability under the age of 65 years who is named in the attached schedule (not to be displayed). Date of last inspection 21st September 2004 Brief Description of the Service: Swan Hill House is a privately owned Care Home registered with the Commission for Social Care Inspection to provide a service for 27 older people and one person with a physical disability under the age of 65 years. It is a well established home situated cliose to the centre of Shrewsbury Town. The Home is owned by Mrs Carol Daker. She is also the registered manager and has day-to-day management responsibility for the Home. The accommodation offers comfortable living facilities with an attractive enclosed and well-maintained garden. There is an established staff group providing service users with consistency in a warm comfortable atmosphere. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on the 20th June 2005 over five hours and was carried out as a routine announced visit. A full tour of the premises took place and a sample of four staff files and three residents’ care records were inspected. Five of the staff on duty, 12 of the residents and two visitors were spoken to at length. What the service does well: What has improved since the last inspection? 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. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 7 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 standard(s) 3, 5 & 6 The home has a satisfactory and functional admissions procedure providing an effective needs assessment and suitability evaluation for both privately funded residents and those placed by the local authority. EVIDENCE: Prospective residents at Swan Hill House are admitted via the local social work team, directly from hospital or through a private arrangement with no social worker involvement. In all cases cases, and confirmed in the residents’ files inspected in detail, the structure of the home’s plan of care for the daily living of each person forms a natural assessment process to identify their individual needs. This is further complemented in some cases by a community care assessment or a hospital discharge document. All residents are offered a ‘free’ one-week trial period, during which time the home’s assessment of care is completed. One senior staff member is responsible for all assessments and care planning. One individual’s assessed care needs reflected in her care plan. was followed through and the inspector confirmed the information and received positive comments from both the resident and also her visiting relative on the day. The relative specifically reported her satisfaction with the process of admission for her mother. There is no intermediate care provided at Swan Hill House. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 8 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 standard(s) 7, 8 & 9 There is a clear and consistent care planning system in place to adequately provide staff with the information they require to satisfactorily meet residents’ needs The completion of records for the administration of medication is not acceptable and could potentially place residents at risk. EVIDENCE: Within the care plans inspected there is good evidence of maintained health care for residents with clear notes being kept. A senior staff member talked confidently through the process and explained the system of recording changes and performing monthly reviews to ensure that residents’ information is always current. One resident spoke of a fall whilst out walking which and had a brace fitted to her wrist. This was cross-referenced to her care notes. Another resident spoke of her mobility and of the pleasure she gains from going for walks. Her involvement with the visiting physiotherapist is working well and she is hoping to soon be able to walk unaided. Her visiting relative said that she was very pleased with the service being provided for her mother. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 9 All aspects of health and social care are addressed including personal history and day / nighttime routines and a ‘cardex’ system is used for recording on going issues and for daily reference by staff. Feedback from two district nurses was received. They reported on the management and staff as always being very helpful and friendly, that residents appeared happy and settled and received very good care. It was reported that all staff involved with the administration of medication have completed a Certificate in the Safe Handling of Medication course. A lockable refrigerator has been installed in which to keep medication requiring this facility It is noted however that record sheets are not being completed correctly at the time of the administration of medication and gaps are being left with no explanation reported. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12, 13 & 14 Swan Hill House provides a good quality lifestyle for the people in residence. EVIDENCE: Residents said that they are in touch regularly with friends and family members and spoke about receiving their visitors throughout their daily routine. The visitor’s book showed considerable activity. Residents reported taking part in activities that match their individual preferences, which could include reading, gardening, walking and shopping. There is a member of staff employed for four days per week to organise group activities such as quizes, bingo or trips out. Another feature of the home is the production of a newsletter aimed at the residents, staff and family members alike. This is a well-presented publication containing interesting articles concerning ‘Swan Hill’ life. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16 & 18 The home has a satisfactory complaints system and there is evidence that residents feel that their views are listened to and acted upon. There is a staff training issue with regard to the arrangements for the protection of residents from abuse, which the manager is currently addressing. EVIDENCE: The home has a complaints procedure, which is referred to for information in the Service User Guide. There is a system of recording complaints and it was noted that there were no entries. There have been no complaints directed to the Commission for Social Care Inspection within the previous 12 months. Residents reported however that their views were always listened to by both management and staff. The home has a policy in place with regard to the protection of residents from abuse. This policy includes whistle blowing and ‘bad practice’ issues. A senior member of staff spoke of the difficulties encountered by the home towards obtaining training in the protection of vulnerable adults and confirmed that he would be attending shortly and cascading the information down to all staff. The home also has a policy concerning residents’ money and financial affairs. Residents either manage their own financial affairs or rely on family members for support. Staff have attended moving and handling training to equip them in their role. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19, 20, 23, 24, 25 &26 The home continues to provide a good quality, comfortable and safe environment for those in residence. EVIDENCE: There is a good size communal lounge / dining room where residents can sit and enjoy the views of the garden. There is also a smaller sitting area where residents can relax alone or with friends and family visitors. One resident said that she enjoyed the quiet, where she can sit and read in comfort. A French window leads out from the larger lounge into the garden. The easily accessible level grounds are secluded, well kept and attractive for residents’ pleasure. All residents’ rooms are well furnished which includes their own possessions. Residents confirmed that they were very comfortable in their rooms and had everything that they needed. One resident had recently moved back into her room after refurbishment and reported that she was very pleased with the result. There is currently a mini programme of refurbishment to some of the SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 13 rooms to upgrade them and provide an en suite toilet for the benefit of those in residence. The Home was observed to be clean and well maintained with a good standard of furnishings and décor. With the exception of one room, the home is free of offensive odours throughout. It is however noted that a more robust cleaning routine is required in this room due to there being a shared occupancy. One resident requested that her door be ‘wedged’ open due to the hot weather. This is an ongoing issue for some residents and advice has been sought with regard to fitting devices linked to the fire alarm to enable this to happen in safety. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 & 30 There is a stable staff group working positively and enthusiastically to provide the residents with a quality of life that meets their individual requirements and aspirations EVIDENCE: Staff files confirmed that a robust recruitment process is in place at the home. Training records are also kept in each individual’s file, which included evidence of induction and foundation training in the form of comprehensive workbooks. Staff on duty confirmed that they all attend mandatory training including fire safety, moving and handling and food hygiene. Residents spoke highly of all the staff with one suggesting that they ‘worked hard’ and are ‘very caring’ towards them. A visiting family member stated that staff presented as being friendly l and helpful. She further commented that she visited most days and always observed a very caring environment. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 36, 37 & 38 The systems for resident consultation are good with evidence suggesting that their views sought and acted upon. The management team are developing and maintaining a well-supported staff group in the home’s quest to constantly improve the service to meet residents’ aspirations. EVIDENCE: The home was seen to have a quality assurance policy in place. This involved service user surveys regarding the more general aspects of life at Swan Hill as well as more specific issues such as food and medication. The manager explained how these are acted upon and used to guide further practice. Records were seen to be stored in a secure and appropriate manner. Documents and records viewed include supervision, training, recruitment, staff SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 16 and residents’ files and health and safety and were seen to be consistent and with the exception of the MAR charts as outlined in the health and personal care section of this report, appropriately maintained. The health and safety records folder confirmed that all checks and maintenance is carried out regularly and appropriately. A retired fire officer is providing further fire training for all staff including those on night duty. Residents choose to have control over their own money and the home has no involvement with residents’ finances. Staff supervision is carried out regularly every 6-8 weeks with notes kept in order to support them in their work. Discussions with the staff on duty during the inspection confirmed that the proprietor operates the home in an open, positive and inclusive manner. SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 2 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 3 x x 3 3 3 SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13.2 Requirement The home is required to ensure that all records for the administration of medication are completed correctly at all times The home is required to provide ‘protection of vulnerable adults’ training for all staff 23.2.d The home is required to ensure that a regular and effective cleaning programme is in place to provide a pleasant and hygienic environment for all residents experiencing incontinence difficulties Timescale for action Immediate 2. 3. 18 26 13.6 23.2.d 22.08.05 Immediate 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 Good Practice Recommendations SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE 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 SWAN HILL HOUSE E56 S20728 Swan Hill House AI V217010 200605 Stage 4.doc Version 1.30 Page 20 - 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. 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