Inspection on 05/12/07 for Swan House Care Home

This inspection was carried out on 5th December 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Swan House Care Home 24/09/09

Swan House Care Home 03/04/09

Swan House Care Home 11/04/08

Swan House Care Home 06/06/07

Swan House Care Home 07/06/06

Swan House Care Home 26/01/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Swan House Care Home Swan House Care Home Pooles Lane Willenhall West Midlands WV12 5HJ Lead Inspector Ann Farrell Unannounced Inspection 5th December 2007 09:00 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.V355897.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 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.V355897.R01.S.doc Version 5.2 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 swanhouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited 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) Vacant Care Home 45 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (45) of places Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 45 The maximum number of service users to be accommodated is 45. 2. Date of last inspection 6th June 2007 Brief Description of the Service: Swan House Care Home is a purpose built two-storey property, which is divided into three units for the purpose of providing care. The home accommodates up to 45 residents with dementia, social care and/or nursing care needs. The environment on the dementia wing has been created to provide residents with the best possible living accommodation for residents diagnosed with this condition so it best suits their needs. All bedrooms have an en-suite toilet and wash hand basin, so enhancing the arrangements for privacy. Residents have the opportunity to take their own furniture and decorative items in to the home, so providing a homely atmosphere. There is a lounge/dining room on each of the units enabling residents socialise and take their meals together if they wish. A passenger lift provides access between floors that enables resident’s access to all areas of the home. Communal toilets and assisted bathing facilities are strategically located throughout the premises, so they are easily accessible to resident’s bedrooms. The home provides all support services in house including laundry, catering and housekeeping. The home is situated on a local bus route, adjacent to local shops. Information in the form of Service User Guide and Statement of Purpose were available on entering the home, which provided information about the services and facilities, but this required updating to enable people to make an informed choice about moving into the home. The information did not include details about the current fees payable. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that needs further development. This was the second inspection for 2007/2008 and was conducted over two days commencing at 7.30 am. The home did not know we were coming. The manager was present for the duration of the inspection. Information for the report was gathered from a number of sources: on the day of inspection a tour of the building was undertaken, records and documents were examined in relation to the management of the home, conversation with managerial and care staff plus visitors and some residents. Some residents were unable to communicate their views verbally to the inspector so direct and indirect observation was used to inform the inspection process. Three residents who live in the home were’ case tracked this involves establishing individuals experience of living in the care home by meeting or observing them, discussing their care with staff, looking at care files, and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. Concerns were identified at the time of inspection in respect of staff’s response to call bells and insufficient staff to meet resident’s needs. As a result of the concerns a referral was made to the adult protection team and a meeting was held to discuss the issues and follow up strategy. Contracting has been suspended temporarily with the home whilst social workers and a nurse from the Primary Care Trust undertakes reviews of all nursing residents. Managers from the organization were also present at the meeting and have increased the staffing level by one carer on the morning shift on the nursing floor and they have made a commitment to undertake reviews of residents needs, so that adequate staffing levels can be identified to meet residents needs. What the service does well: Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 6 The home is a purpose built care home offering single bedrooms with en-suite facilities, so that resident’s privacy is enhanced. The environment was clean ensuring that residents living at the home live in pleasant surroundings. Residents’ are able to bring in their own possessions into the home so they can personalise their own bedroom, ensuring that residents have a personal space that reflects their likes, preferences and individuality. Fresh fruit and vegetables were available to residents; ensuring healthy options were available that meets healthy eating recommendations. The environment within the dementia care unit has been created based on good practice guidelines and recommendations, ensuring that residents who have dementia are living in an environment that best suits their needs. Residents and relatives in this part of the home expressed satisfaction with the care provided Visiting was flexible so that residents are able to maintain contact with friends and relatives. Visitors stated they were made to feel welcome by staff. What has improved since the last inspection? What they could do better: There must be an adequate number of staff on duty at all times to ensure all residents needs are met in a timely and consistent manner. There needs to be a more pro-active approach to care with monitoring, early identification of concerns and appropriate intervention and referral to health professionals where required to ensure residents needs are met. Systems must be put in place to ensure all residents are registered with a GP who will visit the home following admission to ensure medical needs are met effectively. The systems for dealing informal concerns/complaints need to more robust to ensure learning is achieved and re-occurrences do not occur. Also robust systems need to be in place to ensure residents are safeguarded, ensure poor practice is identified and appropriate action taken. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 7 The assessment and care planning process needs to be enhanced to ensure all resident’s needs are identified and consistently met by staff who are familiar with the agreed plan of care. Systems must be in place to ensure call bells and requests for assistance are responded to promptly and courteously by all staff. A review of all equipment must be undertaken and appropriate action taken to ensure residents receive equipment to meet their needs to include chairs, beds etc. The medication system needs to be more robust to ensure residents receive the medication prescribed to them. Further staff training is required to ensure staff have the appropriate skills and knowledge to care for residents effectively and in a consistent manner. The shortfalls in respect of communication need to be addressed to ensure resident’s needs are met and outcomes are positive by a fully committed and positive staff group. Formal staff supervision and staff meetings should be implemented to ensure staff receive appropriate support, guidance and communication is enhanced to benefit resident living in the home. 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 Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 8 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.V355897.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The information that was available to prospective residents and their representatives was not accurate and up to date to enable them to make an informed decision about moving into the home. Assessments had not been consistently undertaken in respect of all prospective residents needs before they moved into the home. Therefore it could not be guaranteed that their needs could be met on entering the home. EVIDENCE: The home generally admits residents who require long-term nursing or personal care. Residents who require personal care only are cared for on the ground floor. Generally residents who require nursing care are accommodated on the first floor, but there are times when some residents who require nursing care are also accommodated on the ground floor residential unit, with no nursing staff permanently based in this area. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 10 On entering the home there was a very pleasant reception area with seating and information was available about the home in the form of a service user guide and statement of purpose. On inspection of the service user guide it was not up to date and had only part of the Commissions report included from 2005, which was out of date. A full copy of the latest report should be available for anyone visiting the home. The other documents should be updated to ensure accurate information is available to prospective residents and their representatives to enable them to make an informed choice about moving into the home. Consideration should also be given to providing it in alternative formats that are accessible to resident’s e.g. large print, audiotape etc. Residents admitted to the home usually require long-term care, but on occasions people are admitted for respite care. It was stated that an assessment of residents needs would be undertaken before they are admitted to the home to determine if staff could meet their needs. On inspection of the record for a resident who had recently been admitted to the home there was evidence of a pre-admission document, but it had not been signed and dated by the person undertaking the assessment. However, on closer examination it was noted that some areas had been dated with the date they were admitted to the home. This suggests that an assessment was not undertaken prior to them moving in to the home. Without this it cannot be guaranteed that the home will be able to meet residents needs. The new manager stated that since she took up the post she had visited prospective residents in order to undertake an assessment. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning need developing further to ensure all residents’ needs are identified and met in a consistent manner. Residents health care needs were not consistently met in an effective manner and there needs to be a more proactive approach to care and follow up to ensure residents well being is maintained. The shortfalls in the medication system cannot guarantee that residents were receiving the correct dose of medication prescribed by health professionals. EVIDENCE: The home is divided into three areas. On the ground floor there was a separate unit for residents who require personal support due to dementia and a unit for residents who require support for reasons of personal care. The first floor is used for residents who require nursing care, although a small number of nursing residents were also cared for on the ground floor, some of whom have been resident in the home for a number of years Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 12 Following admission to the home staff write a care plan for residents, which should outline resident’s needs and the action required by staff to meet their needs. On inspection of a sample of records it was found that risk assessments had been completed in areas such as manual handling, falls, nutrition, tissue viability, and continence. This enables staff to identify risk areas and put systems in place to reduce risks. There was also the ability to record a resident’s life history, so providing staff with valuable information in order to draw up a person centred plan of care. The care plans for residents on the nursing floor were not comprehensive and statements were vague regarding the action required by staff to meet residents needs e.g. check regularly, full hoist and slide sheet for pressure relief and moving, provide fluids on a regular basis , assess bowel pattern and reflect on elimination chart. Although they had been reviewed approximately once a month the records were poor with comments such as, “no change”. This is not adequate to ensure that resident’s needs are consistently met. On inspection of a file for a resident on the nursing floor it was noted that the life history had not been completed. It identified that they were at risk of falls and the plan stated they should be checked regularly and they should have a call bell within reach. However, they were sat in a chair in their bedroom and the call bell was not accessible. On discussion with them they required help and the inspector progressed to ring the call bell and she stated, ”They won’t tell me off will they”. Another resident stated, “I got told off for using the buzzer”; “I have to wait a long time for the toilet”. Whilst touring the home it was noted that a number of residents could not access a call bell and some were banging on the wall or bed table with an object in order to get attention. In some cases call bells had been silenced and a green light was flashing outside the bedroom indicating that a member of staff was present, but no staff member was present. On another occasion a resident called for assistance, staff responded and asked them if they could wait as another resident was in need, to which they agreed. The staff attended to the other resident, but did not return to the original resident promptly. At the time of the last inspection some concerns were raised about the length of time residents had to wait for a response to the call bell and the previous manager undertook some audits and records did not show any serious concerns. A number of residents were sitting in the lounge. they did not have access to a call bell to summon assistance and no staff were present. The inspector sat in the area for approximately one and a half hours and during that time a resident was requesting a drink, but there was no member of staff to assist. A drink was given by the inspector and at one stage a member of staff did enter the room for a short period and responded to the request. On discussion with some visitors they highlighted the fact that their relative did not have access to a call bell to summon assistance at times. At the time of inspection there were Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 13 three care staff and one nurse on the nursing floor and many of the residents required the assistance of two members of staff due to their needs. In instances where residents requests for assistance are not responded to it results in unmet needs. Due to the serious nature of the concerns a referral was made to the adult protection. A decision was made to temporarily suspend admissions to the home whilst social workers and a nurse from the Primary Care Trust undertake a review of nursing residents. A resident required a hearing aid to assist with communication and it was part of the care plan, but no hearing aid was in place. Records for a resident stated to change their position two hourly and records indicated that this was not occurring consistently. Also a continence assessment identified problems with accessing the toilet and removing clothing. The care plan for continence management was for the use of incontinent pads rather than a toileting programme. So although there were care plans they were not being fully implemented as stated. It was noted that some residents had wounds, which required dressing. In one case there was no care plan and an entry in the daily notes identified the issue one day, but there was no follow up to indicate what was happening about the wound. In another case there was a care plan and a record of dressings completed on one day two months previously, but the current state of the wound could not be determined from the records. It was therefore difficult to follow aspects of residents care. Also there was no form of evaluation tool to monitor progress such as photograph or graph. In one residents file it was noted the risk assessment indicated they were nutritionally at risk on admission to the home, but there was no indication of any specific action being taken until they lost some weight. On discussion with a member of staff they stated the residents was no on any special diet and on discussion with the kitchen staff about fortified diets they stated only breakfasts were fortified. In another residents records it was identified that they were experiencing symptoms associated with a urine infection, but the staff did not take prompt action. There needs to be a more proactive approach to care to ensure all residents needs are met in a timely manner. Whilst touring the home it was noted that some nursing residents did not get out of bed and it was stated that it was because there was not a suitable chair for them to sit on, a number of nursing remained in bed and divan type beds also one resident did not have a foot stool that was sufficiently high to elevate their legs and was using the bed. A review of the equipment such as beds, chairs etc. should be undertaken and action taken to ensure appropriate equipment is in place to meet resident’s needs. A complaint was received by the Commission prior to visiting and one of the elements was in relation to the provision of a raised toilet seat. From the Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 14 records it appeared that it had been requested by the relative and was provided. However, staff should be identifying where equipment is required to meet resident’s needs and appropriate action taken by the management to ensure it is supplied. At the time of inspection the inspector observed two hoists in the home and on the second day of the inspection it was stated there was only one in working order. Since the inspection the manager has provided evidence of three hoists and it appears that staff had not charged one, so it was not available for use. Systems must be in place to ensure all hoists are in order and fit for use at all times of the day. On arriving on the second day of inspection it was identified that staff had used the wrong size sling when hoisting a resident. Although an accident had not occurred these practices put residents at risk. Also on discussion with some staff about the use of equipment it appeared that slide sheets were not used when moving residents in bed. The record of staff training indicated that 88 of staff had undertaken updated training respect of manual handling. A review of the training and practices in the home needs to be undertaken by the manager to ensure good practice is implemented. Some poor practices were noted in respect of infection control on the first floor e.g. staff walking around the home with apron and gloves on, dirty linen and pads on the floors in residents bedrooms. The record of staff training indicated that 93 of staff had completed training in respect of infection control. A nurse saw the nursing residents who were cared for on the residential unit when an intervention such as medication or a dressing was required. However, there was no formal system where a nurse reviewed their condition on each shift. It is recommended that this area be reviewed and action taken to formalise a system of review to ensure their needs are met and identify any concerns. The care plans for residents on the residential unit were much more comprehensive and person centred. However, it was noted that a resident had sustained a bruise and this had not been recorded by staff at the time, there was no indication of how it may occurred, there was no investigation to determine to reason despite the fact that the care plan identified that the resident was at risk of bruising and relatives had not been informed. Where there is any bruising or marks on residents they should be reported recorded and investigated if the cause is unknown. Long stay residents were registered with a local GP practice, who visited when requested by staff. However, the new manager stated that she was hoping to meet with the GP’s to see if it would be possible to arrange regular visits in order to review residents. A resident had been admitted for respite care who lived in the Walsall area. When staff called the GP for assistance he did not Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 15 visit as it was out of his area and they had to rely on the out of hours service. Staff must ensure that when residents are admitted to the home arrangements are made for a GP or the existing GP will visit the home. There was no evidence of health checks for residents with chronic diseases such as diabetes, asthma, high blood pressure etc. Records indicated that the chiropodist visited some residents regularly, but there was no evidence of regular visits by the optician or dentist and no indication of the arrangements for residents where the chiropodist did not visit. Records must clearly indicate how health care needs are being met so that residents well being can be assured. The medication was stored in locked medication trolleys within a locked room on each floor. Upon inspection the trolley and cupboards were found to be orderly. The homes medication system consisted of a blister and box system with printed Medication Administration Record (MAR) sheets being supplied by the dispensing pharmacist on a monthly basis. On inspection of the medication for the current month it was found that the majority of blistered medication was satisfactory, but some of the audits of boxed medication were not accurate. Generally the medication on the residential unit was of a better standard than for the nursing unit. Areas that need to be addressed: • Medication had been signed by staff as administered and it remained in the blister pack for one resident. • In one case it stated to take Paracetamol as directed, but there were no directions for its use. This is not appropriate and all prescriptions should state the dose and frequency of medication to be administered. • In some cases there was no record of the amount of medication entering the home and so the medication could not be audited to determine if it had been given correctly. • Two staff had not countersigned handwritten medication details. • Eye drops and creams had not been dated when opened. All creams and eye should be dated when opened and discarded after specific timeframes to reduce the risk of bacterial contamination. • Staff stated there was no suction equipment in the home for use in the case of an emergency. • There were no details as to how medication should be administered via feeding tubes. The ground floor medication room appeared hot at the time of inspection, but there was no record of the temperature. This should be monitored on a regular basis to ensure medication is stored within the product liability licence and is suitable for use. The temperature of the first floor medication room was being monitored and it was 25-26 degrees. This should be maintained below 25 degrees. The minimum and maximum temperature of the medication fridge was being monitored regularly on the first floor and it was found that the maximum temperature was above normal limits. This was checked at the time of inspection and it appears that staff were not re-setting the thermometer after each reading. There was no record of fridge Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 16 temperatures on the ground floor and staff will need to commence this practice to ensure medication is stored correctly. The record of controlled medication and disposal of medication was satisfactory. Generally residents were well presented in a way that reflected their gender, age, culture and time of year. There were occasions when some residents heir dignity was poorly respected e.g. some residents hair was poorly arranged, nails had not been cleaned, spectacles were not cleaned. It one case a resident stated that they had not had a bath or hair washed for the last three weeks. A review of the arrangements for resident’s personal hygiene should be undertaken and systems put in place to ensure individual needs and preferences are identified and actioned. Bedroom doors had locks, lockable facilities were available in bedrooms and en-suite facilities were available, so enhancing arrangements for resident’s privacy. There was a pay phone in the reception area. The new manager stated that where privacy was required residents could use her office. However, there were a number of residents who were in bed all the time, so this may not be possible. Therefore the arrangements for telephone calls needs to be reviewed to ensure there are suitable facilities required when needed. To make and receive calls in private It was identified that there were two residents who resided in the home who smoked, but there were no facilities for them and they had to go outside the building. Where the home accepts residents who smoke suitable arrangements should be put in place to meet their needs. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The choice of food was not always suitable to meet resident’s preferences and ensure they received an adequate nutritious intake. Visitors could visit at time that suited them enabling residents to maintain contact with them. An activities co-ordinator has recently been employed to address shortfalls in activities and provide more stimulation for residents. EVIDENCE: Arrangements for visiting were flexible enabling relatives to visit at a time that suited them and residents to maintain contact with them. Relatives spoken to at the time of inspection stated that when they visited they found staff pleasant and they were kept informed of any incidents. The manager stated they had recently employed an activities co-ordinator, but they were no present on the days of inspection to ascertain the arrangements. This will have to be followed up at the next inspection. On discussion with residents they stated they had recently had a Halloween party, there was evidence that some residents had gone out to the local shops and there was a notice on the board about submitting suggestions for individual Christmas Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 18 wishes. On discussion with some residents they stated it was better in the summer as they could go out in the garden, which was pleasantly set out. Some residents stated they did get bored at times and would appreciate more activities/entertainment etc. to help pass the time. The home employs separate catering staff who provide breakfast, lunch and evening meal. There was a new cook in post, who has had considerable experience in the past. At the time of visiting she stated there was no rotating menu and she had drawn up a menu at the beginning of the week. On discussion it was stated that they had not received the list with residents choices from the care staff for the meals that day. The breakfast was of a good standard with a choice of cereals, porridge, eggs, beans, bacon or sausage. However, on the first day of inspection the breakfast was not served at approximately 9.30 on the nursing unit and some residents had been up quite some time at that stage. It is recommended that this be reviewed, so that residents do not have to wait excessive times for breakfast. On the day first day of the inspection there was a choice of roast beef or a ploughman’s salad for lunch. The inspector had roast beef and the portions were good, seconds were offered and it was of a good standard. Assistance was given by staff where required and on discussion with residents they stated the meals were variable and they were offered choices sometimes. The new cook stated that she was hoping to visit residents individually to discuss their likes and dislikes and so draw up a rotating menu. Robust systems must be put in place to ensure that all residents are asked about their preferences on a daily basis, so their preferences and nutritional needs are met. Diets were catered for and diabetic, puree and fortified meals were available. However, it was identified that only breakfast is fortified. This area will need to be reviewed so that there is fortification of all meals for those residents who require it to ensure that their nutritional needs are met. There was a dining room/lounge on each of the units so residents could dine together providing a social environment. The residential and dementia units were nicely decorated, so providing a pleasant environment for residents to take their meals. There was a combined dining room/lounge on the first floor, but a large number of residents have meals in their bedrooms or in their chair within the lounge. This does not provide people with an opportunity to benefit from the social aspects of mealtimes. The inspector found the table and chairs on the nursing unit were not suitable as they did not provide the correct height for eating. The manager stated that she was hoping to change one of the other communal rooms on the first floor into a dining room and would be purchasing some new furniture, which should enhance the dining experience for residents. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 19 Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems in the home for dealing with complaints and concerns were not sufficiently robust to provide residents or their representatives with confidence that their views will be acted upon. Some staffs knowledge about safeguarding procedures needs further development to ensure residents are consistently protected. EVIDENCE: The record of complaints indicated that there had been nine formal complaints since the last inspection. On examination of the file they included areas such as the call bell not being answered, staff attitude towards residents, drinks not being available and things missing from resident’s rooms. The Commission received a complaint about staff issues in the home and this was referred to the organisation to investigate. As a result of their investigation they informed the Commission a number of changes took place to improve the working within the home. The Commission have also been in the process of investigating another compliant in respect of poor care practise and this was referred to the adult protection team for review. They have made a decision not to take any further action and the findings of the complaint will be referred to the organisation, so that they can take any necessary steps to prevent any re-occurrences. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 21 At the time of inspection discussion with relatives highlighted concerns that included clothing going missing, residents not having access to the call bell or a drink and one stated there had been some mix up with medication that involved an agency member of staff. When they discussed it with the manager she assured them that she would pass it on to all staff to raise awareness, but when the relative visited the next time nurses had not been made aware of the issue. Some relatives stated that if they did raise complaints they were usually addressed. Prior to the inspection the Commission received a further complaint, which was investigated. It included aspects of communication between staff and with families about changes in residents condition, identifying and reporting changes in a resident’s condition, the lack of appropriate equipment, poor quality meals and lack of choices. These issues have been addressed in other parts of the report and were found to be upheld. Whilst it is inevitable for concerns and complaints to be raised in a large home, such as this. It is concerning that similar issues are repeated and there do not appear to be systems in place to prevent reoccurrences. There needs to be a more robust system to address any shortfalls identified and ensure learning takes place to prevent reoccurrences. The home has policies and procedures in respect of safeguarding residents and since the last inspection a considerable amount of training has been undertaken. Records indicated that 90 of staff had received training in this area. On discussion with a small sample of staff about aspects of the safeguarding procedures there was still some vague responses. Also some of the complaints and aspects of practice seen at the time of inspection suggest that further training is required in this area to ensure resident’s needs are met and they are fully safeguarded. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ live in a well-maintained environment with their own possessions around them, so enhancing the area and providing a more homely environment. EVIDENCE: The home was a modern two-storey building, which was cleaned to a good standard, odour free and well maintained, so providing residents with a pleasant environment to live. There was adequate parking space available. The garden areas for residents were located at the front and back of the home and were accessible to residents, allowing them to go outside for a change of scenery if they wished. On entering the home there was a pleasant reception area with some information about the home. There was level access into the building, which Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 23 was suitable for residents who use wheelchairs or have mobility problems. On the second day of the inspection it was found that the front door was not locked properly and this could pose a security risk to residents. The maintenance man was checking the locking mechanism on the door later that day. There was a range of aids to assist with mobility e.g. handrails, grab rails, raised toilet seats and a passenger lift that gave access to all areas in the home All bedrooms were single with en-suite toilet and wash hand basin. All bedrooms were furnished satisfactorily and some had been personalised by residents, so providing a homely environment. All bedroom doors had locks and lockable facilities were available in each room, so enhancing the arrangements for privacy. It was noted that a number of items such as incontinent pads etc were stored on the floor. A review of the storage facilities and arrangements will need to be undertaken so equipment and supplies are not stored on the floor, due to risks of infection. Bedrooms were individually and naturally ventilated and windows were provided with restrainers for safety and security reasons. Radiators and hot water temperatures were regulated to reduce the risks of accidents from scalds. There was a range of communal toilet and bathing facilities with a choice of bath or shower. At the time of inspection a number of extractor fans were not working and some required cleaning. Also one of the bathing facilities on the first floor was out of order and it was stated that it had been like that for some time. Communal space consisted of a combined lounge/dining room on each floor. In each of the areas was a small kitchenette area, which had a sink, fridge, cupboards and equipment for making drinks and snacks, which was very good. On inspection of the kitchenette area on the nursing floor it had not been cleaned adequately, cups/mugs were stained/dirty there were no glasses available in order to make a cold drink for residents, the kettle and extractor fan were not working. Although liquid soap was available there were no paper hand towels. The door on the fridge in the kitchenette of the residential unit was rusting and will need replacing. All bedrooms and communal rooms have a call system enabling residents’ to summon assistance when required. As identified earlier in the report issues were identified with responding to call bells ion the first floor and this was confirmed on discussion with residents and relatives. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 24 The dementia unit was bright and cheerful with a range of colours and fabrics to stimulate residents. There was a separate garden room that was well decorated and lead out to the garden. There was a separate themed bathroom that was pleasant and provided stimulation for residents. The laundry was well equipped. On discussion with visitors and part of the complaint being investigated indicated that items of clothing had gone missing or there were times when other residents clothing were found in their relatives wardrobe. A review of the laundry system will need to be undertaken to ensure these issues are addressed and residents received their own clothing/laundry within acceptable timescales. There is a separate main kitchen where meals were prepared and sent to the units in heated trolleys. On inspection it was found that some areas required attention to improve food hygiene conditions. One of the windows was damaged, paint was peeling from the wall and the areas needed re-decorating. There was no stand for the chopping boards, some new pans and baking trays were required and they could benefit from a potato peeler, as a member of staff has to peel all the potatoes by hand each day, which can be time consuming for such a large number of residents. There was a range of fresh fruit and vegetables, so giving the residents the opportunity to receive a healthy diet. Fridge, freezer and hot food temperatures were being recorded and were within satisfactory limits. The new cook is in the process of developing a cleaning rota and stock rotation system. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 25 Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 26 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There was not sufficient staff on duty to meet residents needs. Further staff training, monitoring and supervision are required to ensure staff have the appropriate skills and knowledge to meet residents needs and good practice is consistently implemented. Recruitment practices need to be more robust to ensure that staff employed are suitable to work with vulnerable people and they are adequately protected. EVIDENCE: There are 23 residents on the nursing floor and a further three residents on the residential unit who require nursing care. Duty rotas demonstrated that there was one nurse and three care staff on the nursing floor during the day and two care staff on each of the residential units on the ground floor. Overnight there was one carer on each unit plus a nurse on the nursing floor. Catering, domestic, laundry, maintenance and administration staff supported care staff. There were a number of residents on the residential unit who required the assistance of two staff, so a member of staff from another unit would have to go and assist during the night. The findings of the inspection indicate that there was not sufficient staff on the nursing floor to meet the current residents needs due to their dependency. Feedback was given to the home manager Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 27 and the senior manager about the need to increase staffing levels and a letter requiring urgent action was sent following the inspection. The Commission has been informed that staffing levels on the nursing unit have been increased by one carer in during the morning. The manager will need to monitor this each shift to determine if the staffing levels are adequate to meet resident’s needs. If any shortfalls are noted they must take further action to address the issues. A sample of staff records were inspected to determine the recruitment process. It was found that staff had completed an application form, health declaration and a Protection of Vulnerable Adults Check had been obtained (POVA) however, there was only one reference on some files. The full Criminal Record Bureau Check (CRB) are kept at head office. . At the time of inspection the checks on nurses registration numbers were not up to date. This will need to be followed up to ensure they are registered to practice as nurses in the home. Records indicated that staff had undertaken a large amount of training earlier in the year covering all core areas such as fire prevention and drills, manual handling, health and safety, safeguarding, infection control, nutrition, medication, dementia with between 86 -93 of all staff having completed the training, which should ensure staff have the skills and knowledge to care for residents. However, during the inspection shortfalls were noted in respect of some areas of practice. Management must review the arrangements for training, how it is implemented and supervision of staff to ensure there is not a gap between theory and practice, so that good practice is implemented and resident’s needs met effectively. It was stated that induction training was provided for new staff, but on inspection of a sample of records for new staff there was no evidence of induction training. The manager must ensure a record of induction is retained in the home of induction training completed that meets the Social Skills Council standards. Less than 50 of care staff had completed NVQ level 2. This is an area where training will be required to further enhance the knowledge and skills of staff. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents living at the home have not benefited from a home that has being well managed. Although various policies, procedures and systems are available they are not implemented in a robust manner to ensure residents’ needs are met. EVIDENCE: The registered manager had ceased employment and a new manager had just taken up the post at the time of the inspection. She is a trained nurse with a number of years experience working in care setting. She had not submitted an application form for registration with the Commission at the time of inspection, but stated that it was in the process of being addressed Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 29 At the last inspection there were a number of requirements that required attention. As a result of the issues the senior managers visited the home to investigate the concerns, implement changes, monitor systems and review the progress. As a result the residential units appears to be performing satisfactory but there are still a number of shortfalls for nursing residents that need to be addressed. There was a matrix with information about formal staff supervision, but on inspection of records it was found that it had not been carried out as often as stated on the matrix or in some cases it did not state the areas or issues discussed. It was not clear from the record if staff who supervision junior staff had received training in how to undertake the process. On discussion with staff they stated that supervision meetings were held sometimes and staff meetings would be held whenever they felt they needed one. Staff were pleasant and helpful, but morale appeared to be low. These area need to be addressed as they could be impacting on the care provided to residents. Residents’ personal money was stored safely. The records of residents’ money had been computerized, so the system did not permit two signatures to be obtained for each transaction. Receipts were found to be available for residents’ money inspected, so ensuring an audit trail could be followed. This was found to be satisfactory, so residents can be assured that the organization has systems in place to protect their money. The home also has a comforts fund where money is collected from fund raising to be used for the benefit of residents. On inspection of the records it was noted that some of the money was used to purchase items that the home should ordinarily be responsible for e.g. material for curtains, carpet cleaner, taxi to the hospital etc. This area will need to be reviewed and systems put in place to ensure the money is used for additional items for the benefit of residents. Health and safety on the whole was well managed and many areas had been checked and equipment serviced e.g. fire and emergency lighting equipment, nurse call system. Areas that were outstanding that need to be addressed include the gas appliance check and the electrical wiring installation check. There were also some areas in respect of the fire officer and environmental health officer’s report that were outstanding and will need attention to ensure health and safety in the home. The organisation has an extensive quality assurance system, which includes a number of audits and questionnaires for various stakeholders. These were not seen at the time of inspection and no development plan was available. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 30 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 2 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 2 X X X X X 2 STAFFING Standard No Score 27 1 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 2 3 2 1 X 2 Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 31 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 OP3 Regulation 14 Requirement Staff must undertake a pre admission assessment for all residents before they enter the home to ensure their needs can be met in all aspects. . All documents must be clearly signed and dated by the member of staff undertaking the assessment. All care plans must be based on a comprehensive assessment and following this assessment a holistic person centred care plan must be drawn up. Short-term conditions and complications must be incorporated into the care planning process to ensure a holistic approach to care takes place and resident’s needs are met effectively. Timescale of 30/9/07 not met. Systems must be in place to ensure staff are aware of residents needs and the action required to ensure they are met. Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 32 Timescale for action 01/02/08 2 OP7 15(1) 30/09/07 3 OP8 13(4) 23(2)(n) 4 OP8 12(1) 5 OP8 12(1) 6 OP8 12(1) 37 7 OP8 12(1) 8 OP8 13(5) 9 OP8 13(3) Appropriate aids and equipment must be in place at the point of admission to the home or change in a resident’s condition to ensure their needs are met appropriately. Timescale of 30/9/07 not met. There must be a proactive approach to care with early detection of any risks/concerns/complications and systems in place to ensure they are addressed promptly or referred to an appropriate health professional where necessary. Systems must be in place to ensure residents have access to a call bell at all times, it is responded to in a timely manner and resident’s needs or requests are met appropriately. Systems must be in place to ensure any incidents of bruising or marks on residents are reported, recorded and followed up appropriately with an investigation or referral to appropriate agencies if the cause is unknown Appropriate systems must be in place for the management of residents continence needs, so that it is managed effectively and the resident’s comfort is maintained. Timescale of 30/9/07 not met. Systems must be in place to ensure resident’s manual handling needs are addressed in accordance with good practice and staff practice is monitored to ensure correct procedures are followed. These are required to ensure the safety of residents. Systems must be in place to ensure good infection control practices to reduce the risk of cross infection. DS0000066099.V355897.R01.S.doc 30/09/07 01/02/08 07/12/07 01/02/08 30/09/07 16/01/08 01/03/08 Swan House Care Home Version 5.2 Page 33 10 OP9 13(2) 11 OP16 22 Robust medication systems must be in place to include: • The correct administration and recording of all medication must be in place and it must be auditable to demonstrate that residents receive their prescribed medication. • The medication room temperature must be maintained at below 25c or below to ensure that medication is stored at the approved temperature. Timescale of 30/7/07 not met. Management of complaints must be reviewed and action taken to ensure systems are in place to ensure learning and prevent reoccurrences. Further training and supervision of staff is required in respect of adult protection to ensure residents are fully safeguarded. Action must be taken to ensure there is an adequate number of staff on duty at all times to meet residents needs. Timescale of 30/9/07 not met. Staff files must contain evidence to demonstrate that two references have been obtained and residents’ well-being is protected. Timescale of 30/8/07 not met. A full review of training arrangements, implementation of training and supervision of staff to ensure staff have the appropriate knowledge, good practice is implemented and residents needs are met Systems must be in place for regular servicing/testing of • Gas equipment. • The electrical wiring. DS0000066099.V355897.R01.S.doc 30/07/07 01/02/08 12 OP18 13(6) 01/03/08 13 OP27 1 30/09/07 14 OP29 Sch 417(1) 30/08/07 15 OP30 18(1) 01/03/08 16 OP38 13(4) 01/03/08 Swan House Care Home Version 5.2 Page 34 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The service user guide should be reviewed and updated to give accurate up to date information, so that residents or their representatives can make an informed decision about moving into the home. Alternative formats should also be available so information is more accessible to residents. Where residents have a wound an objective tool should be used to enable evaluation e.g. photograph or graph Systems must be in place to ensure all nursing residents are reviewed at least once each shift by a qualified nurse and records made of this, to ensure their nursing needs are being met. Systems must be in place to ensure residents have the opportunity to see health professionals such as chiropodist, dentist, optician etc on a regular basis and records kept of visits or where the service is refused, to ensure residents health needs are met. Systems should be in place to ensure health checks for residents with chronic diseases such as diabetes, high blood pressure, asthma etc and records should be retained to demonstrate residents health care needs are met. Systems must be in place to ensure all residents are registered with a local GP who is prepared to visit the home. A full review of all manuals handling equipment must be undertaken and action taken to ensure there is an adequate supply of the full range of equipment to meet residents needs. A review of the communication systems in the home should be undertaken and actions taken where any shortfalls are identified to ensure resident’s needs are met effectively. (Carried forward) It is suggested that the lead nurse from the PCT is contacted for advice and guidance regarding the administration of subcutaneous fluids to ensure safe and appropriate procedures are followed and resident’s needs are met. (Carried forward as not inspected) DS0000066099.V355897.R01.S.doc Version 5.2 Page 35 2 3 OP7 OP8 4 OP8 5 OP8 6 7 OP8 OP8 8 OP8 9 OP8 Swan House Care Home 10 OP9 Ensure a robust medication system to include: • All medication should have clear directions about its use. • Two staff must countersign handwritten medication details. • Eye drops and creams must be dated when opened and discarded within specific timeframes to reduce the risk of bacterial contamination. • Details must be available as the procedure for the administration of medication via feeding tubes. • Ensure suction equipment is available in the home for use in the case of an emergency. Systems must be in place to ensure residents receive a bath and assistance with personal care, hair nails etc to meet their needs and preferences and ensure their dignity. Suitable arrangements must be in place to ensure all residents can access a phone to make telephone calls in private if they wish. Suitable arrangements must be in place for residents who wish to smoke. Persons living in the home must have access to activities, which consistently reflects their needs and preferences, so they receive appropriate and adequate stimulation. (Carried forward as not inspected) Draw up a menu based on residents preferences over a four to six seek period to ensure residents receive a varied diet and nutritious diet. Ensure all residents are offered a choice of meals at all mealtimes to ensure they receive a variety of foods that meets their needs and preferences. The serving times of breakfast must be reviewed for residents to ensure that they do not wait excessive amounts of time before they are given the first meal of the day. (Carried forward) Provide a stand for chopping boards in the kitchen to ensure adequate hygiene standards. An audit of all extractor fans must be undertaken and repaired if not in working order. The fridge in the ground floor kitchenette should be replaced as it is rusting. The bath on the first floor should be repaired to ensure there are adequate assisted bathing facilities available to all residents. Residents should be offered a key to their bedroom unless their risk assessment indicates otherwise and a record of DS0000066099.V355897.R01.S.doc Version 5.2 Page 36 11 12 12 13 OP10 OP10 OP10 OP12 14 15 16 OP15 OP15 OP15 17 18 19 20 21 OP19 OP19 OP19 OP21 OP24 Swan House Care Home 22 23 24. OP26 OP26 OP28 25 26 OP29 OP30 27 28 29 30 31 32 OP32 OP32 OP33 OP35 OP36 OP38 this conversation is kept in the care plan, in order to enhance privacy. (Carried forward) All areas in the home must be kept clean at all times to include kitchenettes and extractor fans to ensure adequate hygiene. Review the laundry system and ensure robust procedures for returning residents clothing in a timely manner. At least fifty percent of care staff working at the home should have an NVQ 2 qualification or equivalent in care, so that they have the skills and competence to meet resident’s needs. (Carried forward) Evidence of nurses PIN number check must be kept in the home to demonstrate they are registered to work as a nurse. The induction programme for newly employed care staff must reflect the contents of the Skills for Care programme and records must be retained in the home to ensure staff are adequately trained initially to undertake their role. It is recommended that regular staff meetings be held to assist with improvements in communication. Action should be taken to address issues affecting the staff morale, so that there is good team working and improved outcomes for residents. It is recommended that regular meetings be held with residents in order to gain feedback about aspects of the home and provide them with some control over their lives. The use of the comforts fund should be reviewed to ensure it is used appropriately to enhance the life of residents living in the home Regular formal staff supervision, should be undertaken by competent trained staff in order to support and guide staff and enhance outcomes for residents. . The recommendations made the Environmental Health Officer and Fire officer should be addressed to ensure the home is safe Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 37 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. Extracts may not be used or reproduced without the express permission of CSCI Swan House Care Home DS0000066099.V355897.R01.S.doc Version 5.2 Page 38 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!