Inspection on 21/02/06 for Swan House

This inspection was carried out on 21st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 38 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 19/01/07

Swan House 09/05/06

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 Alison Ridge Unannounced Inspection 21st February 2006 08:50 Swan House DS0000062628.V279346.R01.S.doc Version 5.1 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.V279346.R01.S.doc Version 5.1 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.V279346.R01.S.doc Version 5.1 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 Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That South Birmingham Primary Care Trust informs the CSCI of their intentions for the future management of the home by 31 May 2005. 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 11th July 2005 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 Care Housing Association owns the premises. At present the home accommodates six men. The men all have a Learning Disability, some have impaired mobility, and some have some behaviours that challenge. The accommodation comprises of six single bedrooms, a communal lounge, dining room, a w.c, supported bathroom, shower room, kitchen and laundry room. The home has a garden at the rear of the home, with garden furniture and shade. The homes registered manager was due to return to the home, in the week of inspection, after a period of development, at other homes within the trust. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the inspector’s second visit to the home, and it was undertaken over the morning and early afternoon of one day. The information used in this report was collected by observing the support and care offered to the service users accommodated, talking with service users and staff, looking around the premises, and reading records about care, health and safety and staffing. This is a home that CSCI has identified as needing significant development to ensure that the needs and wishes of the men accommodated are fully met in the way they prefer. Since the last inspection it was clear some work to address these concerns has been undertaken, but a large number of previously made requirements remain unmet. It is suggested this report be read alongside the report of inspection undertaken on July 11 2005 to get a fuller picture of life in this home. The inspector extends her thanks to the men, and staff who assisted with this inspection. What the service does well: The men who live at Swan House generally get on well with each other and with the staff who support them. It was pleasing during the visit to see the men and staff talking, laughing and undertaking activities together. The design of Swan House means that all the men have a single bedroom, and that there is plenty of space to be by yourself, or with others if you choose. The food available, and planned on the menu was very varied. The staff prepare a lot of the food from fresh, and the amount of fresh meat, and vegetables used was great. The men were observed to enjoy the lunchtime meal, which smelt very tasty. The staff generally give the medication as prescribed. Only one audit that was undertaken did not add up. The staff mainly manage service users money well. The records available showed that the money is checked regularly, and that the staff record purchases and get a receipt. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The décor and flooring in the home requires attention. In many places the wallpaper or paint is damaged, and the floor in some parts of the home looks very dirty or worn. This has been identified at previous inspections and needs to be addressed. The care plans for the men have previously been assessed as being out of date and confusing. They don’t include the wishes of the person that the plan is about. The staff had received some information about this, but work to develop these is still urgently required. The staff had not always ensured the men’s healthcare was being monitored, and in the two files assessed the men had not been weighed since May 2005. This is a specific need for one of the men tracked. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 7 The records show that some incidents have occurred where one of the men has harmed another of the men that lives in the home. The incident had not been reported to the CSCI or Social care and Health, and it wasn’t clear what action the manager and staff had undertaken to ensure the same thing doesn’t happen again. Staff records did not show that recruitment checks had been made on staff, or that they had received an induction and all mandatory training. This was raised before as a serious concern. The health and safety of the men, staff and visitors had not been safeguarded by checks of the assisted bath, electrical hard wiring, or fire safety and fire fighting equipment. 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 DS0000062628.V279346.R01.S.doc Version 5.1 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.V279346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X These standards were not assessed. EVIDENCE: These standards were not assessed. The home has a stable service user group, and there are no residential vacancies. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Service users needs and risks are not well planned for. This could result in service users needs being unmet. Service users records are stored securely and information about them is passed sensitively. EVIDENCE: The complete plan of two service users were assessed and another one in part. The plans had been sorted into better order, but the content had not been altered since the previous inspection. The staff had explored the commencement of new plans, which would better address service users needs, and which would be more person centred. To date these have not been commenced. The work undertaken with one service user in readiness for a care review was assessed. It was very positive that staff and the service user had considered in advance of the meeting the issues to be discussed. The inspector considered this very positive practice. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 11 The record keeping system within the home had improved, and all personal files about service users were securely stored. Staff were respectful in the way they communicated with service users. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 17 The frequency and range of activities have increased, but service users do not have regular, planned, access to a range of interesting and varied activities with the same frequency as their peers, who don’t live in a care home. Some positive work to consult with service users prior to a care review had been undertaken, but service users are not involved in routine decision-making about their care or lifestyle. EVIDENCE: The records of activities offered to two service users during February 2006 were assessed. It was clear the number of opportunities had increased, and it was pleasing to hear one of the men talk about trips he had undertaken, and a meal eaten in a local pub, he had enjoyed on the evening prior to inspection. The planning of activities needs to continue to improve to ensure a range of interesting and varied opportunities are provided. Staff records about activities need to improve to clearly state the activity undertaken, and if the service user enjoyed or benefited from it. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 13 It was positive during the visit to see service users being encouraged to participate in household tasks. It is recommended that this be formalised as part of the service users plan, to promote development of new skills and to enable evaluation of the effectiveness of the plan to be undertaken. The service users daily notes showed contact with service users family where possible. It was apparent another service user was supported to remember his family in a way that was important to him. The record of food eaten, the menu and food available at the time of inspection was improved. The menu showed a greater degree of choice, and that a more nutritious menu was being planned and offered. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Service users personal care needs appeared well met. Healthcare needs require better planning and recording to evidence service users are receiving all care and support required. Service users medication is generally given as required, work is required to ensure as required medicines, creams, non-blister packed and emergency medicines are well managed. EVIDENCE: The inspector was pleased to meet all six of the service users who reside at Swan House. During the morning the men were supported with personal hygiene. This was at a time they choose. The men all appeared very individual, and it was apparent they had been supported to shave, and undertake nail care. The service users accommodated have a range of health needs. It was not evident that these were well planned for. One service user is at nutritional risk, and has a low body mass index. The plan of care identifies he should be weighed regularly. No information on the goal weight or BMI was available. Weight records showed he was last weighed in Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 15 May 2005, and did not evidence any review with the dietetic service had been undertaken. The plan of care to underpin one service users epilepsy has previously been identified as requiring development, and the support in this area to be reviewed. The inspector found the plan of care and medication prescribed to be unchanged. The service user is prescribed a rectally administered rescue medication. Staff are not trained to give this. No review with the GP or consultant had been undertaken. This was a requirement at the last inspection. One service user tracked has some difficult to manage behaviours that cause harm to others and him. The way in which this had been planned for had not changed since the last inspection. Staff reviewing the plan of care had identified in August 2005 that the plan required re-writing yet no work to address this had started. The records of incidents were very ad-hoc and no consistent monitoring of the number or intensity of incidents was being undertaken. It was not evident that plans of care or risk assessments had been reviewed after critical incidents. Examples of falls and challenging incidents were identified that had not been further explored. Service users had been offered appointments with the dentist, optician and GP as they required. It was not evident nail care or foot care was being given as required, or that the twelve month referrals had been made to chiropody as requested by the department at the last review. Key areas of need such as personal care, continence, night care needs, communication and eating and drinking were not planned for. Medication management was assessed, and generally it could be established that service users were receiving the right medication at the right time. Requirements were made in July 2005 about the need to review, update, sign and date protocols for as required medicines. This remains outstanding. Creams were found in two of the three service users rooms inspected that had been open far in excess of 28 days as is required. The staff need to effectively audit medicines not blister packed. The one medication assessed did not tally with records available. The remainder of staff need to be trained to give medicines. The rota showed some nights where staff qualified to administer medication were not on duty. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Threats to service users safety and welfare are not well assessed or planned. Action to protect service users from harm is not adequate. EVIDENCE: The daily records and record of incidents reported to the provider identified that incidents had occurred where one service user had caused harm to another of the service users accommodated. It was not evident that these had been reported to the CSCI, or to Social Care and Health. It was not possible to establish that staff had undertaken action, or put plans in place to reduce the likelihood or prevent such an incident re-occurring. An immediate requirement regards the reporting of these incidents was made. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 30 The environment at Swan House was identified as requiring attention to the furnishing and décor, to ensure the comfort and safety of service users. EVIDENCE: The design of Swan House is good, as it enables all the service user to have a single room. There is a good amount of communal space, which means that there is a choice about where to sit, and whether to be alone or with others. The décor and flooring in the home requires attention, as this is now significantly damaged, or very dirty. The furniture in the lounge showed signs of heavy wear, and the dining room furniture was poor. It was reported that a dining table has been provided from another unit. A selection of odd chairs, some of which were very dirty had been provided. The fronts of kitchen units were observed to be lifting, and the worktops were damaged. Staff reported that this work is all scheduled to be undertaken. Timescales in which it would be addressed were not known. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 18 Staff had routinely recorded hot water delivery temperatures. These were often cool at between 33 and 36°c. It is recommended that these be kept under review, and increased to 43°c. The inspector was pleased to be shown three service users bedrooms. These all contained items important to each individual. The standard of cleanliness in all areas of the home had much improved, and no offensive odours were evident. The number of yellow clinical waste bags exceeded the storage bins. It is required arrangements for the storage and disposal of these full bags be reviewed and addressed as required. . Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 36 The number of permanent staff is not adequate to continuously meet service users needs. Staff require ongoing training and supervision to ensure they have the skills to undertake their role effectively. Recruitment practice is not robust to ensure service users interest are protected. Staff had been supervised on a regular basis, to a good standard. EVIDENCE: The staff on duty worked in a positive and supportive way with the service users. It was evident that the staff on duty were important to the service users, and they were kept informed when asked about people not on duty. The rotas did not evidence that adequate numbers of staff were always provided, and in the three weeks sampled examples of two staff being on duty were evident. The inspector was seriously concerned about this. Other occasions when it would result in two staff being on duty were noted when staff were rostered to work a long day, and would take a ninety minute break, reducing the number of staff on duty to two over this period. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 20 The risk assessments available showed that some service users required two staff to assist with personal hygiene. Service users also require staff supervision to ensure their safety from each other or from falls. The inspector did not evidence this could be effectively undertaken with two staff on duty. Five staff files were assessed. None of these contained the complete range of recruitment records required. None of the files evidenced that staff had received all mandatory or service user specific training. There were no records in three of the files to show induction had been undertaken. This was brought to the provider’s attention at the last inspection in a letter of serious concern. The staff files sampled showed that staff had received detailed supervisions, and that this had been undertaken at least six times a year. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 41, 42 The ongoing management and operation of the home was of concern. Work was identified as being required to ensure the outcomes for service users are safe, well planned; and consistently met. EVIDENCE: A temporary manager has managed the home since May 2005. The registered manager was due to re-commence work in the home, in the week of inspection. It was evident that the acting manager had worked hard with staff to improve on the delivery of care, but many outstanding requirements regards the planning and recording of this were noted. There was a current certificate of registration and insurance on display. The registered provider had not undertaken regulation 26 visits as is required. The senior social care manager had undertaken monitoring in December 2005. Records showed this had not been undertaken prior to this since July 2005. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 22 The care records were not easy to use. Information about care needs was located approximately half way down a large lever arch file, and it is recommended this be reviewed, to ensure staff have ready access to the important information. Records about service users money with the exception of one entry were complete. The inspector was concerned that records were made on loose pages, and in one of the files sampled they were not numbered. Staff were completing the financial record on two sheets (personal money summary and service user expenditure sheet). These did not easily cross reference with each other. The inspector was concerned that the service users current financial balance was located in the back of the large lever arch file, and that this did not promote staff to check the balance against the money available when doing a handover. This could result in an error going unidentified for a number of shifts. It is required this be reviewed. The record of incidents reported to the provider showed incidents that should also have been reported to the CSCI under regulation 37. It is required this be undertaken. The staff had got better at testing the fire alarm and emergency lighting. At the time of inspection this was up to date. It was evident that gaps of up to five weeks without a test had occurred. (13/1/06-3/2/06; 13/12/05-30/12/05; 6/10/05-17/11/05) Staff must ensure this is undertaken as required. A fire drill had been undertaken in February 2006. A requirement of the last inspection was that this be undertaken by July 13 2005, as it was outstanding since November 2004. Records to evidence that the assisted bath, electrical hard wiring, and fire alarm system and equipment had been serviced were not available. The fire risk assessment (21/12/05) identified work as being required to improve the fire safety of the home. Confirmation that this has been addressed is a requirement of the report. Staff had undertaken a monthly health and safety audit. This was positive, and should be continued. Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 23 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 X 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 X 23 1 ENVIRONMENT Standard No Score 24 1 25 2 26 2 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 1 34 1 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 3 LIFESTYLES Standard No Score 11 2 12 2 13 2 14 2 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 1 2 X 1 X X X 1 2 X Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 24 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 YA6 Regulation 15 12(1)(a) Requirement Timescale for action 01/07/06 2 YA6 3 YA6 4. YA9 5. YA9 6. YA9YA19 Unmet from the previous inspection. Care documents must clearly state peoples needs and how these are to be met. 12(2) Unmet from the previous inspection. Service users known wishes and preferences must be recorded in the plan. 12(2) Unmet from the previous inspection. 15(1-2) Service users must be kept informed of the content of plan, and it kept under review with them. 12(4)(a-c) Unmet from the previous inspection. Risks faced by service users must be underpinned with a risk assessment. 12(4)(a-c) Unmet from the previous inspection. Clinical risks must be assessed and plans implemented to manage them. 13(4)(b-c) Critical incidents and near misses must prompt a review of risk and care documents and care DS0000062628.V279346.R01.S.doc 01/07/06 01/07/06 01/07/06 01/07/06 01/05/06 Swan House Version 5.1 Page 25 practice. 7. YA12 16(2)(mn) This had improved, but not fully met. The range and frequency of activities available to service users in the home and community must be increased. Unmet from the previous inspection. Evidence as to how activities were decided upon and their purpose must be included in the service users plan. Unmet from the previous inspection. Guidelines must be developed regards one service users eating and drinking needs. Strategies to ensure service users can eat undisturbed must be developed. Not assessed at this inspection. Staff must receive awareness training regards service users needs. Unmet from the previous inspection. Clear guidance on how clinical and care needs are to be met must be provided. Unmet from the previous inspection. An Epilepsy care plan must be developed, and the use of rescue medicines reviewed with the GP Unmet from the previous inspection. Reactive plans and behaviour protocols must be developed if required. Unmet from the previous inspection. All relevant health care appointments must be offered to all service users and a record of such maintained. Unmet from the previous DS0000062628.V279346.R01.S.doc 01/05/06 8. YA13 16(2)(mn) 01/06/07 9. YA19 12(1)(a) 13(6) 01/06/06 10. YA19 18(1)(a) 01/07/06 11. YA19 12(1)(a) 13(1)(b) 15 12(1)(a) 13(1)(b) 15 12(1)(a) 13(6) 01/06/06 12. YA19 01/06/06 13. YA19 01/06/06 14. YA19 12(1)(a) 13(1)(b) 01/05/06 15. YA19 13(4)(c ) 01/05/06 Page 26 Swan House Version 5.1 12(1)(a) 16. YA20 13(2) 17. YA20 13(2) 18. YA20 13(2) 19. 20. YA20 YA23 13(2) 13(6) 21. YA24 23(2)(a) 22. YA24 23(2)(b) 23. YA24 23(2)(b) inspection. Records of physical health must be monitored and the required support obtained when required. Unmet from the previous inspection. All prescribed medication must be available and listed on the MAR chart. Unmet from the previous inspection. Systems to audit non-blister packed medicines must be developed and used within the home. Unmet from the previous inspection. The use of rectally administered medicines must be reviewed with the GP. Systems to ensure their safe administration must be developed if they continue to be prescribed. Creams must be dated when opened, and used or discarded within 28 days Unmet from the previous inspection. All possible strategies and actions must be implemented to protect service users from harm. Security arrangements and the perimeter fencing must be reviewed and increased as required. No work undertaken since last inspection. A schedule of replacement and redecoration with timescales must be developed and forwarded to the CSCI. Unmet from the previous inspection. The dining room chairs must be clean, fit to use, and adequate seating provided for all service users. DS0000062628.V279346.R01.S.doc 01/05/06 01/05/06 01/05/06 01/05/06 01/05/06 01/07/06 01/08/06 01/08/06 Swan House Version 5.1 Page 27 24. YA24 23(2)(b) 25. 26. 27. 28. YA27 YA30 YA33 YA34 23(2)(j) 16(2)(k) 18(1)(a) 19 Sch2&4 29. YA35 18(1)(a) 30. YA35 18(1)(a) 31. YA37 9 32. 33. YA41 YA41 26 37 34. YA41 13(6) 35. YA42 23(4)(c) (iv) Unmet from the previous inspection. The kitchen must be maintained in a satisfactory state of repair. Work surfaces accessible to the service users accomodated must be provided. Water temperatures must be increased to 43°c Secure storage for clinical waste prior to collection must be obtained. Adequate staff must be on duty across the day. Unmet from the previous inspection. Recruitment records must evidence robust procedures are in use, and that staff are fit for work. All new staff must receive an induction to the home, and a record of this must be maintained. Not assessed at this inspection. An audit of training delivered and required must be undertaken, and training as identified delivered. The registered provider must ensure the management arrangements at the home are adequate for the service. Regulation 26 visits must be undertaken monthly and a record of such maintained. The CSCI must be notified of incidents reportable under regulation 37 without undue delay. Systems for recording and auditing service users money must be reviewed to ensure they are robust and safeguard funds. Unmet from the previous inspection. Fire alarm, and emergency light tests must be undertaken DS0000062628.V279346.R01.S.doc 01/08/06 01/05/06 01/05/06 01/06/06 01/05/06 01/05/06 01/07/06 01/06/06 01/06/06 01/05/06 01/05/06 01/05/06 Swan House Version 5.1 Page 28 regularly. 36. YA42 23(4)(a) Confirmation that work as 01/05/06 identified in the fire risk assessment has been undertaken must be provided. Evidence that the fire alarm, fire 01/05/06 fighting, electricity, and assisted bath equipment have been serviced as required must be provided. 37. YA42 23(2)(c ) 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 4 Refer to Standard YA6 YA12 YA24 YA24 Good Practice Recommendations It is recommended that the order in which care records are presented be reviewed to ensure current active material is easily accessible. It is recommended that household activities be included in the service users plan. It is recommended that ways to ensure service users rooms are private to them be explored and developed. It is recommended that cupboards be fitted on the walls in the kitchen cupboards Swan House DS0000062628.V279346.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 House DS0000062628.V279346.R01.S.doc Version 5.1 Page 30 - 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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