Inspection on 26/01/06 for Swan House Care Home

This inspection was carried out on 26th January 2006.

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

The inspector 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 Care Home 24/09/09

Swan House Care Home 03/04/09

Swan House Care Home 11/04/08

Swan House Care Home 05/12/07

Swan House Care Home 06/06/07

Swan House Care Home 07/06/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow 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 Care Home Swan House Care Home Pooles Lane Willenhall West Midlands WV12 5HJ Lead Inspector Richard Eaves Unannounced Inspection 26th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Swan House Care Home DS0000066099.V280138.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 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 Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Swan House Care Home Address Swan House Care Home Pooles Lane Willenhall West Midlands WV12 5HJ 01922 407040 01922 407040 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) Ashbourne (Eton) Limited Ann Marie Simmonds Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: Swan House Care Home is a purpose built two storey property situated on a local bus route, adjacent to local shops. A lift provides access between floors. Surrounded by a small garden the home provides accommodation for up to forty five older persons requiring residential and/or nursing care. Individual accommodation is spacious with the opportunity for service users to bring their own furniture and decorative items. There are two lounges with separate dining facilities. The home provides all support services in house including laundry, catering and housekeeping. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by a single Inspector and drew upon information: the action plan submitted by the home following the announced inspection during August 2005, reports from the organisation relating to the conduct of the home, the pre-inspection questionnaire and records held at the home The inspection included a tour of the building and meeting service users and visitors to obtain their views. The inspection covered the kitchen, laundry, sluice rooms, bathing facilities and the communal areas of the home. A large proportion of bedrooms were entered with permission as it was possible to obtain. Generally the home was found to be functioning calmly and efficiently and service users appear appropriately attired and comfortable and were willing to confirm that they were happy with life at the home. What the service does well: What has improved since the last inspection? Care planning has continued to improve since the previous inspection including contingency planning for specific conditions and inclusion in clinical supervision meetings for nursing staff. Staff are conscious of the need to maintain a visible presence at peak activity times. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 6 Documented visual checks of cold smoke seals fitted to doors ensures they will function appropriately if ever required. 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 Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1- 5 The home provides good sources of information about the home and invites prospective service users to visit and spend time at the home prior to admission to enable them to make an informed decision about entering the home, this is confirmed by contract. Pre-admission assessments are undertaken by the most experienced staff and confirmation is given to the service users that their needs can be met by the home. EVIDENCE: The home has recently reviewed and updated statement of purpose and service user guide, which can be provided in large print format and are available in reception and the guide also in each bedroom. The assessment process is thorough, including all activities of daily living and an extensive range of risk assessments, all assessments are subject to monthly review. The file documents information of the service user or representatives involvement in the assessment process. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 9 Each case file includes a contract and a letter confirming that the agreed assessed needs can be met by the home, the letter also invites prospective service users to take the opportunity to visit and trial the services offered. The home does not offer an intermediate care service. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 – 11 Health care needs of service users are fully met. Care plans are derived from a comprehensive range of assessments and provide the basis for the delivery of care and detail the actions required of staff to meet the identified needs. Arrangements for the administration of medication are good and ensure service users medication needs will be safely met. Service users are treated with respect and their privacy upheld. Staff have been developed to provide care at the time of service users dying with sensitivity and respect. EVIDENCE: A sample of three care plans were randomly inspected on each floor they were derived from extensive assessments of needs and individually assessed risks, these were completed well and provided good direction for the delivery of care. Evaluations were undertaken monthly and included reassessments. A small number of examples of date omission on reviews were observed. Contingency plans for potential health problems have been developed. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 11 All service users are registered with a GP (currently 9 practices serve the home) and the district nursing service visits the personal care only service users on request. Other allied medical services such as dentist and optician are provided on a regular and as required basis. The home uses a Monitored dosage system of medication and the MAR sheets examined by the inspector were clearly printed with relevant details and prescription instructions. A photograph of each service user is securely attached to the corresponding MAR sheet to assist with identification. The manager advised that the home would be changing to the Boots MDS shortly. Controlled drugs are stored appropriately and accurate records are maintained of medication received and returned by the home. A contract is in place for the disposal of pharmaceutical waste including that from the personal care only floor. An assessment of capacity to self medicate is included in the case files although none currently do self medicate. Over the day staff interaction with service users was observed on many occasions and were overheard to use the chosen term of address, knocked before entering bedrooms and were generally respectful and sensitive to the protection of privacy and dignity. In discussion with service users many were able to describe how they are assisted to make choices for themselves in such areas as clothes to wear, where they wish to spend time. The key worker documents individual wishes and routines and staff said that these were implemented flexibly to allow the service user opportunity to make other choices, in response to one lady telling the inspector that she would like to increase the frequency of bathing the staff were able to demonstrate that this has happened. A limited programme of training of care of the dying is included in the NVQ units and the Nursing staff have experience in care of the dying. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 The home provides a limited but well-organised and varied social and recreational activity programme that provides interest and pleasure for the residents with efforts to meet individual and minority needs. An open visiting policy assists service users to maintain contact with their family and friends. Many aspects of care evidences that service users exercise choice and control over their lives. Meals at the home are wholesome and meet the nutritional needs of service users while reflecting choice and taste and catering for special dietary needs. EVIDENCE: The activities co-ordinator has been proactive establishing a broad range of events and activities and has progressed the documenting of a social assessment and life story that assists in providing insight into individual social and recreational likes and needs. A structured programme of activities is prepared on a weekly basis but this is open to providing spontaneous activity and allows time for one to one sessions. A number of service users undertake regular shopping trips and go out with family and other trips are in the planning stage using the company mini bus. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 13 Religious observance is individually arranged with the local vicar providing one to one pastoral care on a regular basis. The home has “open visiting”, on the day of the inspection there were visitors coming and going throughout the day. The care plans identify residents individual likes and dislikes and choices about their individual routines, these are carried out flexibly to provide for choice of the moment. Residents spoken with, as they were able said that they chose what they wanted to wear when to get up and go to bed and how and where they liked to spend their day. The 4-week menu provides for a balanced and nutritious diet and is well received by the residents many able to recall the choices offered at each of the meals and that the three main meals offered a cooked option. The menus have been assessed as nutritionally sound and are put together using a high proportion of fresh produce. Service users receiving the soft option diet also choose their meal from the menu. A supper is provided and snacks such as toast, biscuits and crisps are always available. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 – 18 The home complaints and protection policies are robust providing a safe environment in which service users feel they can voice concerns and that these will be listened and responded to. Service users rights are protected and staff demonstrate excellent knowledge and understanding of adult protection issues which contributes in providing an environment safe from abuse. EVIDENCE: The complaints procedure is well promoted in the service user guide and in notices displayed in numerous places about the home. Records demonstrate that concerns raised are acted on and that the staff are receptive to personal wishes. Advocacy services are also displayed in the main reception area. The manager identified that the electoral roll is completed each year and confirmed that postal votes had been arranged for the coming year. The home has a robust adult protection policy and all staff have undertaken adult protection training. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 – 26 The home provides a good standard of décor, furnishings and managed services providing a safe environment and an attractive, comfortable and homely place to live. The home is clean, free from odours and hygienic. EVIDENCE: A tour of the building found the home to be clean, hygienic and free from offensive odours. Decoration is in good order with some having been undertaken recently, the bedrooms and communal areas are comfortably furnished to provide a homely environment. The home has a modern equipped laundry that complies with all standards and each floor has a sluice disinfector available with staff hand wash in these areas provided with controlled hot water. The infection control policy was readily available to staff. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 The home has a good mix of staff in sufficient numbers to provide consistency of care that meets service users needs. The home has been proactive in developing a skilled staff group with understanding of service users needs. Recruitment and selection processes are to a good standard protecting vulnerable people. EVIDENCE: The rotas confirm that numbers across the 24hour period and skill mix of qualified and unqualified staff are appropriate to the needs of service users. The ancillary services provide a full 7-day service. Staff met and spoken with were enthusiastic and those who were recently employed received formal induction that meets TOPPS standard. The standard of 50 of care staff being trained to NVQ level 2 standard has been exceeded and continues to be increased with further carers enrolled. Each member of staff has their own training folder and a matrix is maintained for ease of monitoring completion of mandatory training. Recruitment and selection is completed to a good standard and includes all necessary checks such as CRB, POVA and nursing registration. Staff files also show that two references are obtained and records kept of interviews. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38 Leadership of this home is good and staff demonstrate an awareness of their roles and responsibilities and service users benefit from this consistency. The home regularly reviews its performance which includes consultation and seeking the views of service users and their families and evidenced that it is acted upon. The sound financial management of the home and arrangements for safekeeping of their money safeguards service users interests personal and financial. Staff receive supervision and direction to ensure that the service users receive consistent quality care. The best interests of service users are safeguarded by the homes record keeping, policies and procedures. The safety and welfare of service users is protected. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 18 EVIDENCE: The manager is a registered nurse with experience in care home management, currently studying for the Registered Managers Award. A unit manager leads the personal care section on the first floor and a senior nurse leads nursing on the ground floor. Many staff gave the view that morale at the home is high and the senior staff are very approachable and work closely with staff. Regular staff meetings also support this with good communication. The last full satisfaction survey of service users was undertaken in June 2005 the report of which is published and displayed and has been the subject of discussion at the regularly held service user meetings. The area manager undertakes monthly unannounced visits in line with regulation 26 requirements, the reports of which are copied to the Commission. The home is not appointee for any service users but do undertake to keep personal allowances the book keeping of which is undertaken with individual accounts giving details of income and expenditure and two signatories for each transaction. Auditing is undertaken by the area manager as part of the monthly visit. Staff supervision is well established at the home, a sample of files show the supervision content to be relevant and taking account of work activities and policies within the homes. An inspection of records required by regulation and listed in the schedules show these to be maintained, up to date, accurate, kept secure and used in accordance with the Data Protection Act. Health and Safety is given appropriate priority with an extensive range of monitoring and maintenance in place. During the tour of the building it was observed that all corridors and fire escape ways were clear. An inspection of the monitoring records show these to have satisfactory results and kept in good order. Staff training in health and safety, fire safety training is satisfactory. Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Swan House Care Home DS0000066099.V280138.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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