Inspection on 19/01/07 for Swan House

This inspection was carried out on 19th January 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Swan House 30/06/08

Swan House 28/08/07

Swan House 09/05/06

Swan House 21/02/06

Swan House 11/07/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Swan House 6 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF Lead Inspector Sarah Bennett Key Unannounced Inspection 19th January 2007 10:40 Swan House DS0000062628.V325135.R01.S.doc Version 5.2 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 Swan House DS0000062628.V325135.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 Adults 18-65. 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 DS0000062628.V325135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swan House Address 6 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QF 0121 444 2710 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) South Birmingham Primary Care Trust Family Housing Association Limited Mr Anirood Nobab Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate six people with a learning disability under 65 years. The home can accommodate three named people over the age of 65 years. 9th May 2006 Date of last inspection Brief Description of the Service: Swan House was purpose built as a care home, on the site of what was previously Monyhull Hospital. South Birmingham Primary Care (NHS) Trust manages the staff and the home, and Family Housing Association owns the premises, which is a bungalow. At present the home accommodates six men. The men all have a Learning Disability; some have impaired mobility, and some display behaviour’s that challenge. The accommodation comprises of six single bedrooms, a communal lounge, dining room, a W.C, adapted bathing facility in the bathroom, shower room, kitchen and laundry room. The home has a garden at the rear and side of the home, with garden furniture and shade. The fees charged are £127.35 per week to Family Housing Association. Each service user pays a contribution to the home’s vehicle and this is dependent on how much Disability Living Allowance the individual receives. A copy of the CSCI inspection report is available in the home for those who wish to read it. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and reports from the provider. This was the homes second key inspection for the inspection year 2006 to 2007. This unannounced key inspection was undertaken by one inspector over one day. The staff on duty, the Acting Manager and the Social Care Manager were spoken to. Conversations with service users were limited due to their complex needs and limited verbal communication. The inspector met with all service users and time was spent observing care practices, interactions and support from staff. A tour of the premises took place. Care, staff and health and safety records were looked at. What the service does well: What has improved since the last inspection? The care plans that show staff how to support individuals had improved and include the wishes of the person that the plan is about. They included pictures to make them easier to understand. Risk assessments were in place for most of the risks to service users. The risks are reduced as much as possible without stopping the person doing the activity or doing as much as they can for themselves. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 6 The room that was the office had been redecorated so that it can now be used as an activity room and give more communal room for the people who live there. New dining chairs had been bought and there were enough chairs for service users and staff to sit down together at mealtimes. New kitchen cupboards had been fitted and there is now a lot more cupboard space for storage and the kitchen is cleaner. Staff have had some training so that they can meet the needs of the people who live there better. Staff had regularly done the fire and health and safety checks to make sure that the people who live in the home, staff and visitors are safe. The Manager has had an interview for registration with the CSCI and is to be registered. This will help to make the management arrangements stable for the staff and the service users. What they could do better: Risk assessments must be in place for how the risks of being hit by another service users are to be reduced. Care plans must include all the needs of individual’s. Referrals must be made to health professionals where needed. A healthy diet must be offered to all service users. Medication must be given to service users as required to make sure their health needs are met. All allegations of abuse must be reported to the relevant people so action can be taken to make sure that service users are protected and are safe. Staff vacancies must be filled so that staff who know the service users well are working with them. Staff must have all the training they need to meet the needs of all service users. Some parts of the home must be redecorated and furniture and flooring replaced so that the home is comfortable, clean and homely. Evidence that the electrical wiring is in a satisfactory condition must be available so it is clear that it is safe. The scratched chopping boards in the kitchen must be replaced so that food can be prepared on a clean surface. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 7 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. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make a choice about whether or not they want to live at the home. EVIDENCE: The statement of purpose had been updated since the last inspection to include all the relevant and required information. This gives prospective service users the information they need so that they and their representatives can make a choice about whether or not they want to live there and if their needs can be met. Each service user had a copy of the service users guide in their bedroom. It was produced using pictures making it easier to understand and included all the relevant and required information. Key workers had stated that it had been read with the individual. There are no vacancies for service users. The current service users have lived at the home for several years. No service users had been admitted in the last year. Therefore, the admission and assessment process was not assessed during this inspection. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans show staff how to support individuals to meet their needs and achieve their goals. Service users are consulted in some aspects of their lives and this will continue to improve with the new review format. Service users are generally supported to take risks within a risk assessment framework to ensure their safety and well- being. EVIDENCE: Two service users care plans were sampled. Care plans detailed information about the individual and how staff are to support them with their diet, communication, leisure and social activities, health needs, epilepsy, managing their behaviour, mobility and during the night. The individual’s routines and likes and dislikes were detailed. Care plans were produced using pictures making them easier to understand. All care plans were regularly reviewed and updated where needed. Service users and their relatives attend their reviews and are involved in developing their care plans. Where appropriate, staff use Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 11 pictures to make it easier for service users to understand what their review meeting is about. Records sampled included evidence that service users had been consulted about buying a new bed. Staff did this by showing the individuals pictures, catalogues and going to the shops. Service users were asked what they wanted for Christmas. Regular service users meetings were not held, as due to the needs of service users they would benefit from individual meetings rather than sitting discussing what they want in a group. The Social Care Manager said that key workers do a monthly review of service users care plans. This review is now produced using pictures so that key workers can do this with service users and seek their views. This was to be shown to staff the following week at a staff meeting to ensure they all know how to develop this with service users. Service users records sampled included individual risk assessments. These included fire, which was produced using pictures, holidays, mobility, behaviour and eating and drinking. One service user had an assessment assessing the risk of them developing a pressure sore. It stated that they were at risk of doing so but no care plan was available. There were no risk assessments about the risk of a service user being hit by another service user. This remains outstanding from previous inspections and is required to ensure that all service users are safe. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are not sufficient to ensure that service users always experience a meaningful lifestyle, giving service users the opportunity to go on holiday would improve this. Service users are offered a varied diet but not all service users have a healthy diet. Special diets are catered for so that all dietary requirements are met. EVIDENCE: One service user goes to a day centre from Monday to Friday. Records showed that service users go to cafes, church, pubs, restaurants, cinema and drives out. All service users went out together for a Christmas meal with staff. Three service users were going to the cinema that afternoon. Staff took the cinema listings off the Internet and sat with service users to choose what film they were going to see. Some daily records showed that activities were cancelled as there was no transport, because money and shopping had to be got so service users were not able to go to the pub or equipment was not working. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 13 The Acting Manager said that when activities are cancelled they are rebooked. In-house activities include watching TV and DVD’s, puzzles, games, arts and crafts, listening to music, foot spa and hand and foot massage. Staff were observed offering service users a choice of DVD’s to watch. Service users were enjoying watching their chosen film. The home has a vehicle. Staff said that there are three drivers including the Manager. The Social Care Manager said that they are continuing to look at whether or not the vehicle is financially viable as service users contribute to this each week even if they don’t use it. Staff said that service users did not go on holiday this year because of staffing and funding but they hope to plan this year. Records showed and staff said that individuals are supported to keep in contact with their family and friends. Care plans stated how each individual would be supported to do this and who the important people are in their life. Staff said that one service user is supported to visit their parent’s grave and to visit the area where they used to live when they were younger. Some service users were wandering freely around the home deciding when they wanted to watch TV or spend time sitting in the dining room. Records showed that service users are involved in household chores including putting their laundry away and cleaning their bedrooms. There are two pet rabbits and staff said that one service user in particular enjoys having them. This service user had also adopted a dog that they have regular news of and photographs, which they enjoy looking at. They can also go and visit the dog. Food records sampled for one service user did not indicate that the individual had the recommended five portions of fruit and vegetables each day. The other service users food records sampled showed that on most days the individual had at least five portions of fruit and vegetables. Shopping is bought on the Internet by staff. Where appropriate special diets are catered for and one service user who is on a gluten free diet has a separate food cupboard. Staff were observed offering service users a choice of drinks. The Dietician is involved in recommending diets for individuals. Fresh fruit and vegetables and adequate food stocks were available. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are not sufficient to show that all service users health and personal care needs are well met. The management of the medication does not protect service users. EVIDENCE: Care plans were very detailed so that staff know how to support each service user with their personal care. Staff were observed supporting service users to change their clothes when necessary. Service users were dressed appropriately to their age, gender, the weather and the activities they were doing. Two members of staff were observed supporting a service user to transfer from their chair to their wheelchair to go and have their lunch. Staff spoke to the individual encouraging them to help themselves to move but did not put on the brakes on their wheelchair, which could have put the service user and staff at risk of injury. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 15 Service users records sampled showed that staff keep records of when individuals have a bowel movement so that action can be taken if they are constipated to ensure their well being. Waking night staff had completed sleep charts for each service user every half hour during the night. Some service users may not require being checked so frequently and this may disturb them. The Social Care Manager said that individual assessments are going to be completed as to how often each person needs to be checked during the night. Each service user had a Health Action Plan. This is a personal plan about what a person needs to stay healthy and what healthcare services they need to access. They were completed using pictures making them easier to understand. Records showed that health professionals are involved in individual’s care where appropriate. These included the Physiotherapist, Dietician, Hearing Consultant, Psychiatrist and Podiatrist. Records showed that service users had regular check ups at the dentist and opticians. Weight records showed that service users are weighed regularly and advice is sought from the Dietician if a person’s weight should increase or decrease. One of the service users records in December 2006 stated that advice had been given from a health professional to arrange for an appointment with a specialist. Staff had followed this up but needed to ring back again but there was no record that this happened. The Acting Manager said that they did not think this had been done would chase it up. Boots supply the medication to the home using the monitored dosage system. One service user was prescribed Rectal Diazepam so that if they have one epileptic seizure after another this can be controlled. The Acting Manager said that a less invasive medication had been considered however as the service user only has a seizure every three years it was felt it was better to continue with the same ‘rescue’ medication if this was needed. The protocol for how and when staff are to give this had recently been updated. At the front of each Medication Administration Record (MAR) there was a photograph of the individual so it is clear for staff who to give the medication to. On looking at the MAR and the monitored dosage pack it was found that only one of the service users had received their night-time medication the previous evening. A separate cabinet is provided for Controlled Drugs (CD) Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 16 prescribed to service users. One of these was not given as prescribed the previous evening. Staff complete a handover of the medication kept in the CD cabinet at the change of every shift. Staff had signed to say they had completed this handover between the night shift and the early shift but had not noticed that it had not been given the previous night. The Social Care Manager said that they would do an investigation into why this was not given and offer further support and training to the members of staff concerned. All other medication had been given appropriately. Staff who give medication had received medication training and been assessed as competent to do so. Protocols for PRN (as required) medication were regularly reviewed and updated where necessary. Service users records showed that they had regular medication reviews. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users and their representatives know how to make a complaint if they are unhappy with the service provided. Arrangements have improved but they need to be consistent to ensure that service users are always protected from abuse. EVIDENCE: Each service user had a copy of the complaints procedure in the service users guide that was kept in their bedroom. It was produced using pictures making it easier to understand. There had been no complaints to the home or the CSCI in the last twelve months. An allegation had been made to the Manager in September 2006 about the care practice of a member of staff. This had not been raised appropriately in line with the Birmingham Multi-Agency Guidelines on the Protection of Vulnerable Adults. Recently the allegation had been raised again to the Acting Manager and this was reported appropriately to the relevant authorities. The member of staff had been moved to protect the service users. A strategy meeting was arranged to decide who will investigate the allegation and what action will be taken to safeguard the service users. Two service users financial records were sampled. The amount in their individual wallet cross –referenced with the amount on their financial record. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 18 Receipts are kept of all expenditure. Where individuals have bought expensive items this had been agreed with the individual and their relative and an agreement to spend the money had been made. Service users contribute to the home’s vehicle and individual agreements are in place for this. The Social Care Manager said that they regularly review the financial viability of the vehicle as service users contribute financially to it each month if they use it or not. Service users records sampled included a detailed list of their belongings that had been regularly updated as they had bought new things or disposed of things and the reason for this. Most of the staff have received training in adult protection and the prevention of abuse. This is outstanding for two staff as the trainer cancelled this earlier this month but the Acting Manager said it will be re-booked. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The decoration and furnishings of the home had improved but more work is needed to ensure that service users live in a homely and comfortable environment EVIDENCE: The lounge was well decorated. There were framed photographs of each of the service users on the walls of the lounge that had been taken recently. Staff said that a new plasma screen TV is to be bought for the lounge and this will make it easier for all service users to see the TV. Service users bedrooms were personalised and decorated according to individual tastes and interests. Some of the service users bedroom carpets needed replacing and staff said that some of them are going to be replaced. The Social Care Manager said that three of the bedroom carpets are to be replaced. The bedside cabinet in one of the service users bedroom was worn and in need of replacing. Other furniture was of good quality and in good Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 20 condition. One of the service users bedrooms was in need of redecorating. A ceiling track hoist is provided in one service users bedroom to assist staff with moving the person safely. There were flashing lights provided to warn service users with a hearing impairment that the fire alarm was sounding. The hall outside the service users bedrooms had been redecorated but the carpet has not yet been replaced. The decoration in the small WC was worn and in need of redecorating. In the shower room the flooring was stained and dirty and in need of replacing to minimise the risk of cross infection. A new boiler had recently been fitted. Staff said that recently the tumble dryer was broken but this had been repaired. The office had been moved to the room off the lounge. The room that used to be the office had been redecorated by staff and is going to be used as an activity room. The flooring in this room is to be replaced to make it more comfortable. Staff said that the chairs in the dining room were replaced last year. There were no lampshades in the dining room and these must be provided to make the room more homely. Staff said that the kitchen had recently been refurbished but it still needed re decorating. A new dishwasher had been provided. The kitchen windows and fly screen were very dirty. These must be regularly cleaned to ensure that hygiene standards are maintained in the kitchen where food is being prepared. The garden at the side of the home is now part of the home and not a public walkway. A fence had been put around the garden at the side to make it more private and secure. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff need to be recruited to ensure that service users benefit from a consistent staff team that know them well. Staff are well supported and have received some of the necessary training to ensure they can meet the service users individual needs. More training is required to ensure that all individual’s needs can be met. The recruitment practices protect the service users. EVIDENCE: The Acting Manager said that 50 of care staff have achieved NVQ level 2 or above in Health and Social Care, which meets this standard. Five care staff are working towards NVQ level 2. The Acting Manager said that there were five staff vacancies. One staff had been moved to a non-clinical area following an allegation and another staff would be leaving soon. This would make 176 hours per week vacancy. The Social Care Manager said that at the Managers meeting earlier in the day this home had been identified as a priority for recruitment. Vacancies are covered with staff working extra hours and bank staff. Rotas showed that bank staff Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 22 were working on most shifts. A member of bank staff was working on the early shift. The minutes of five staff meetings during 2006 were available, one was planned for the following week. The Acting Manager said that there had been another one but the minutes of these were not available. The keys were not available to access staff records that were locked in a filing cabinet. The Acting Manager and the Social Care Manager said that all the recruitment records had been updated and were now available in the home. The majority of the staff had received training in first aid, food hygiene and moving and handling. All but two of the night staff have had training in adult protection and the prevention of abuse. The Acting Manager said that this was cancelled by the trainer earlier in the month and would be rebooked. All staff have had epilepsy training. One member of staff has had training in dysphagia, one staff had training in healthy eating and three members of staff have had sight awareness training. Six members of staff have been assessed as competent to administer medication and another two members of staff have had the accredited training but have not yet been assessed as competent. Staff had not had training in Coeliac Disease or Ageing to ensure they can meet the individual needs of service users. The Acting Manager said that they had tried to book this but there were no dates available for this. A list of supervision dates and whether or not staff had received this showed that staff have had regular, formal supervision sessions with their line manager. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements have improved so that service users benefit from a well run home. Service users views underpin the self-monitoring and improvement of the home. Arrangements are generally sufficient to ensure that service users health and welfare is always promoted and protected. EVIDENCE: The Manager was away on holiday for a month and one of the senior care staff was the Acting Manager. The Manager had recently been interviewed for registration with the CSCI and was successful at interview. A representative of the Provider, Family Housing are now visiting the home monthly as required under Regulation 26. This includes seeking the views of service users and staff and a report is made of their visit. The South Birmingham Primary Care Trust (PCT) completed a detailed audit recently Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 24 following the much publicised ‘Cornwall Report’. Some recommendations from this related to training in Minimising Confrontation and Studio III. The Social Care Manager said that these recommendations would be met and would be prioritised along with other training that was required for staff. The PCT has recently developed a quality assurance system that is comprehensive and seeks the views of service users. Staff tested the fire alarm in the morning to make sure it was working and said they did this every week. All staff had fire safety training in May and July 2006. The fire risk assessment was dated February 2006 and was reviewed in December 2006 to ensure that all risks of a fire starting are minimised as much as possible. An engineer serviced the fire extinguishers in May 2006. Fire drills are held every six months so that staff and service users know what to do if there is a fire. Staff test the water temperatures weekly to make sure they are not too hot or cold. Records showed that these ranged from 37 – 39 degrees centigrade. The recommended safe temperature is 43 degrees centigrade so staff must ensure that the temperature is not lower as this may be too cool. A Corgi registered engineer tested the gas equipment in March 2006 and stated that it was in a satisfactory condition. An electrician completed the annual test of the portable electrical appliances earlier in the month to make sure they are safe to use. An electrician completed the five-yearly test of the electrical wiring in November 2002 and stated that it was in an unsatisfactory condition but did not state why. The Manager had asked what remedial works were required to make it satisfactory and the electrician said that this was a mistake. The Acting Manager said that they are chasing the documentation to verify this. The chopping boards in the kitchen were very scratched and in need of replacing to ensure these are hygienic on which to prepare food. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 2 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 3 x 3 x x 2 x Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 12(4)(a-c) 15 (1) Requirement Where service users have been assessed at being at risk of a pressure sore a care plan must be in place as to how this risk is to be managed. Unmet from the previous three inspections. Risks faced by service users must be underpinned with a risk assessment. This includes a service user being hit by another service user. All service users must be offered a healthy diet. Staff must ensure that safe practices are always used when moving and handling service users. Staff must ensure that action is taken to ensure that service users are referred to specialist health professionals when needed. Timescale for action 28/02/07 2. YA9 12(4)(a-c) 28/02/07 3. 4. YA17 YA18 16(2)(i) 13 (5) 18 (1) (a) 12 (1) (a) 31/01/07 19/01/07 5. YA19 31/01/07 Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 27 6. YA19 12(1)(a) 7. YA20 12 (1) (a),13(2) 8. YA23 13 (6) 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. YA24 YA24 YA24 YA26 YA26 YA26 YA27 YA27 YA30 YA33 23 (2) (b, d) 23 (2) (p) 23 (2) (b) 23 (2) (b) 16 (2) c, 23 (2) c 23 (2) (b, d) 23(2)(d) 23 (2) (b, d) 16 (2) (k) 23 (2) (d) 18(1)(a) Individual assessments must be completed as to how often each service user needs to be checked during the night. All medication must be given as prescribed. Staff must check the Controlled Drugs stored at each handover and keep a record of this. Any allegations of abuse must be reported to the relevant authorities in line with the Multi-Agency Guidelines on the Protection of Vulnerable Adults. The kitchen must be redecorated. Lampshades must be provided in the dining room. The carpet must be replaced in the hall. Where identified service users bedroom carpets must be replaced. The bedside cabinet must be replaced in one of the service users bedrooms One of the service users bedrooms must be redecorated. The WC must be redecorated. The flooring in the shower room must be replaced. The kitchen windows and fly screen must be kept clean. Staffing vacancies must be recruited to. 31/03/07 19/01/07 19/01/07 30/04/07 31/03/07 30/04/07 30/04/07 31/07/07 30/06/07 30/06/07 30/06/07 28/02/07 31/05/07 Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 28 19. YA35 18 (1) (a, c) 20. YA42 13 (4) (a-c) 21. YA42 16 (2) (j) All staff must receive training in: a) Healthy Eating b) Dysphagia c) Coeliac Disease d) Ageing The correct documentation from the electrical wiring test stating that it is in a satisfactory condition must be available. The kitchen chopping boards must be replaced. 30/09/07 28/02/07 30/04/07 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 YA14 YA42 Good Practice Recommendations Each service user should be offered the opportunity to go on holiday each year. Staff should ensure that the water temperatures do not fall lower than 37 degrees centigrade. Swan House DS0000062628.V325135.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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