Inspection on 12/08/05 for Swan House

This inspection was carried out on 12th August 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Swan House 19/05/09

Swan House 20/05/08

Swan House 06/11/07

Swan House 03/04/07

Swan House 24/04/06

Swan House 12/04/05

Swan House 25/10/04

Swan House 01/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Swan House 47 - 49 New Road Chatteris Cambridgeshire PE16 6EX Lead Inspector Elaine Boismier Unannounced 12th August 2005 @ 5:45 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 House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Swan House Address 47 - 49 New Road, Chatteris, Cambridgeshire, PE16 6EX 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) 01354 696644 01354 696645 Four Seasons Homes No 4 Limited Mrs Susan Ann Gough Care home with nursing 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Physical disability over 65 years of age (40) Terminally ill over 65 years of age (25) Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 No more than 25 nursing places 2 No more than 25 places for terminally ill residents over 65 years of age Date of last inspection 12/04/05 Brief Description of the Service: Swan House, close to the centre of the town of Chatteris, is a care home that looks after people over 65 years of age, some who need nursing care. There are 40 single bedrooms and 39 of these have ensuite facilities. Also there are six bathrooms. On both floors of the home there are the bedrooms, a dining room and a choice of sitting rooms; the upper floor can be reached via stairs or a lift. There is a small garden at the back of the home. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection that was unannounced, of Swan House Chatteris for 2005/6. The inspection was carried out by two inspectors between 5:45 and 8:10 am and took 2.5 hours to complete. During the inspection 32 residents were living at the home and 3 of these were spoken to. A tour of the building was made, staff were spoken to and documentation was seen. Systems for medication were also assessed. Following the inspection, due to the Manager being on leave, the Responsible Individual was spoken about the findings of the inspection and comments made by her have been included in this report. What the service does well: What has improved since the last inspection? Since the last inspection of the home there has been an improvement in 3 noticeable areas: Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 6 • Care plans that were seen showed that the home has taken action to meet two requirements made since the last inspection as residents, or their representatives have been consulted about their care. There was some evidence also that reviews of this care involved the residents where it was possible to do so. Information about residents’ medical conditions has been kept confidential. A requirement that was made for the home to take action by 13th April 2005 has been met. The recommendation made following the last inspection (about the agenda for residents’ meetings) was not assessed on this occasion. • • 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 House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 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 standard(s) EVIDENCE: None of these standards were assessed on this occasion. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 9 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, 9 & 10 Residents are actively consulted about their care; their privacy is respected although some practices of safekeeping and recording of medication poses risks to the health and safety of residents. EVIDENCE: Three care plans were seen and evidence suggests that residents, or their representatives have been involved in drawing up their care plans. There was evidence also that reviews of the care included the opinion of the resident. As a result of these findings the two requirements have been met. Records for the administration of medication were satisfactory with the exception of the controlled drug register. The name and address of the dispensing pharmacy was not available. In addition where there was an increase in dosage of medication (and as such a new prescription) the method of recording this change was unclear. This was discussed with the Responsible Individual who agreed that a new page should have been used for a change in the dosage of medication. Two recommendations have been made about these findings. During the tour of the premises keys to access medication were found on a table, unattended, in a communal room. An immediate requirement was made about this serious concern. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 10 Methods to store medication, including air temperatures and fridge temperatures, were satisfactory. During the tour of the building it was noted that confidential information about residents had been removed from a public place. This requirement has been met. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 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 standard(s) 12 Residents have a choice how to live their lives. EVIDENCE: Direct observation noted, and residents confirmed that their choice of when to get up and when and where to have breakfast was respected by staff. Care plans seen indicated that these choices were recorded and reviewed. During discussion with a resident a member of care staff offered the resident a choice of what to wear. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 12 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) EVIDENCE: These standards were not assessed on this occasion. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 13 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 & 26 Residents live in a well-maintained and clean home. EVIDENCE: During the tour of the premises the home was seen to be generally clean and fresh smelling. The Responsible Individual reported that action has been taken to replace the stained carpet in the main, upstairs, communal area and that arrangements have been made for replacement carpets in three bedrooms. The gardens were well maintained and decorated with colourful flowers in hanging baskets. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 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) 27 Residents are cared for by sufficient number of skilled staff. EVIDENCE: Staff on duty at the time of the inspection included a qualified nurse and two care staff. Staff reported that they had been able to meet the needs of the residents and this was also observed whilst speaking to residents. Staff were seen to interact, and care for residents, in an unhurried manner. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 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) 38 Residents feel safe although there are some risks to their safety. EVIDENCE: According to staff and the Responsible Individual doors to enter the home are unlocked after 7 am. However, at the start of the inspection, at 5:45, the front door was unlocked and the Inspectors made direct entrance to the home. A requirement has been made about this. During the tour of the premises it was noted that a member of staff had left, unattended, a cigarette lighter in a communal room of the home. Due to the potential risk of harm to residents, staff and visitors a requirement has been made about this. Residents spoken to said that they felt safe living at the home. Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 16 (Standard 33 and the recommendation made about this standard was not assessed on this occasion). Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x 2 Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP 9 OP 38 Regulation 13(2) 13(4)(c) Requirement The Registered Person must ensure the safe-keeping of medication. The Registered Person must ensure that unecessary risks of safety to service users is eliminated by ensuring the locking of entrance doors during out-of-ours The Registered Person must ensure that unecessary risks of safety to service users is eliminated by ensuring that cigarette lighters etc are kept safely Timescale for action Immediate i.e. 12.08.05 17/08/05 3. OP 38 13(4)(c) 17/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP 9 OP 9 Good Practice Recommendations The Registered Person should include the name and address of the dispensing pharmacy in the controlled drug register The Registered Person should consider safer methods of recording within the controlled drug register ,when a change of medication is made I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 19 Swan House Swan House I53 I03 s24309 SWAN HOUSE v243543 120805 STAGE 4.doc Version 1.40 Page 20 Commission for Social Care Inspection CPC1, Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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