Inspection on 05/05/05 for Swan Lodge

This inspection was carried out on 5th May 2005.

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

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

Other inspections for this house

Swan Lodge 01/08/07

Swan Lodge 10/08/06

Swan Lodge 13/12/05

Swan Lodge 11/10/04

Swan Lodge 29/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Swan Lodge Kent Avenue Wallsend Tyne & Wear NE28 0JE Lead Inspector Irene Bowater Unannounced 05 and 24 May 2005 13:30pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Swan Lodge Address Kent Avenue Wallsend Tyne & Wear NE28 0JE 0191 263 9434 0191 262 1413 swanlodge@fshc.co.uk Tamaris Healthcare (England) Ltd Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant CRH 46 Category(ies) of OP Old age (46) registration, with number of places Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Two named service users under pensionable age. No further service users to be admitted below pensionable age without the consent CSCI. Date of last inspection 11th October 2005 Brief Description of the Service: Swan Lodge is a purpose built care home situated on the same site as another care home owned by the same company. The home provides nursing and social care for up to 46 older persons. There is also a contract with the NHS to provide 6 beds for the local GPs. The home has lounges dining rooms and separate smoking rooms on each floor. All of the bedrooms are single and have en-suite facilities. There is a range of specialist bathrooms,showers and toilet facilities throughout the home. The first floor is accessible by stairs and a passenger lift and the grounds are readily accessible. There is ample car parking to the front of the home. The home shares the kitchen and laundry services with the ajacent home. Swan Lodge is well positioned for local transport and all local amenities. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 2 separate afternoons in May. This was because of serious concerns, which were found on the first day, which resulted in the inspection being stopped in order for the home and company to take immediate action. A serious concern letter was issued and the company met the requirements within the timescales and confirmed their action in writing. A further unannounced inspection took place to complete the inspection and to ensure the appropriate action had taken place. The letters to the registered person are available from the CSCI office. Over the 2 visits a tour of the premises took place, residents and staff were spoken with on both occasions. Care records and other records were inspected on both days. Ten staff, fourteen residents and one visitor were spoken with. On the 2 inspections the Manager from the adjoining home assisted through the inspection. Telephone conversations were also held with the registered person on the first day of the inspection. What the service does well: The home has a team of care staff who have worked at the home for a long time. They are keen to raise standards and are eager for clear direction and leadership. They have developed a good team, are enthusiastic and have a good knowledge and good relationships with the residents. The residents without exception were protective of the staff. They said that the girls are good, they go the extra mile and they are lovely staff. Residents who were only in for a short time said they wished they could stay and were very happy with the care. The recruitment and selection of staff follows procedures, which protects residents from harm. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The home has been without an experienced manager for some considerable time and this has affected the care and services provided for the residents. The home still has not provided a contract for residents who are self funding. Assessments and care planning must improve to ensure that staff know what to do for each resident. The nurses must ensure that all health needs are documented and specialist nurses advice is followed. The social and recreational care of residents must improve to enable them have a quality of life within and outside the home as they wish. Complaints and concerns from residents and staff must be properly looked into and suitable action taken by the home. Staff need training so that residents are fully protected from harm. The home must always be a safe comfortable place for people to live and work. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 7 All staff need to have up dated training in safe working practices, fire training is outstanding for night staff and fire risk assessments are not available. The staff must follow infection control procedures in regard to disposal of clinical waste and keeping all areas fresh smelling. The staff must have access to hot water, liquid soap and hand towels to be able to wash their hands. The laundry equipment must be replaced or repaired to ensure all linen and soiled laundry is washed at the right temperatures. Systems must be in place to ensure the hot water supply is constant and the temperatures accurately recorded. The lighting in the home needs to be bright enough in all areas. The staffing in the home must be suitable to meet residents needs especially at peak times and the home must continue with statutory, specialist training and supervision for staff. The records and record keeping in the home need to be organised and be brought up to date. The home must ensure that the risk assessments for the safe use of bed rails are detailed to ensure residents safety. The dining room chairs should be replaced with carvers, which have a slide facility. The home must inform the commission of all events in the home, which affect the health, safety, and welfare of residents, staff and visitors. The recruitment of a manager is essential to ensure all the above areas are improved upon. 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 Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3. The Home has not yet produced a Statement of Terms and Conditions for residents who are self funding. The rights and obligations of the resident and the provider are not clear as there is no Statement of Terms and Conditions. There is no assurance that residents care needs will be met due to a lack of comprehensive assessments. EVIDENCE: The home has not provided residents with a statement of terms and conditions (or contract) when purchasing their care privately. The Company has comprehensive admission policies and procedures. The care plans showed that the admission assessments were brief and had not been dated. Care management assessments were available, however not all care plans followed the assessment process. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 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 standard(s) 7,8,10 There is no consistent care planning system currently in place to adequately provide staff with the information they need to satisfactorily meet residents assessed needs. The care staff have a good understanding of the residents’ needs. This is evident from the positive relationships, which have been formed between residents and the care staff. The support given protects residents’ privacy and dignity. EVIDENCE: Seven care plans were inspected and the recording and detail varied in all of them. The majority showed that the assessments were brief, monthly reviews had not been carried out and some had only been evaluated once or twice in eight months. The risk assessments that were completed in September 2004 had not been updated and moving and handling and mental health assessments had not been dated or signed. There was evidence of involvement of other professionals regarding nutrition and pressure sore care, however it was difficult to follow the progress as the Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 11 files were disorganised. There was limited information to show that residents and their representatives had been involved in the care plans. Several of the entries had been completed by a senior care assistant and had not been countersigned by a qualified nurse. The care plans did show that the residents have access to all NHS services and facilities. The GP visits on a regular basis and the home provides designated GP beds. Residents who were admitted to these beds were happy with the health care they were receiving. The home is able to access specialist nurses for advice regarding pressure sores, nutrition, and continence care. Residents who had lost weight did not have a detailed care plan regarding their nutrition or what action the nurses were taking. The residents spoke highly of the care staff and said they are well looked after. Comments from residents included “they go the extra mile”; “they are lovely girls” “I am happy with the care”. The residents looked well groomed and were comfortably dressed. The residents who were unwell and remained in bed were comfortably positioned had access to their call bells and their bedding was clean and fresh. The care staff have formed good relationships with the residents. They were observed carrying out all care with sensitivity and in private Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 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 standard(s) 12,13, The home does not provide a social and recreational lifestyle to match the residents’ current needs. The home supports and enables residents to maintain links with the local community and with their families. EVIDENCE: The home still has a vacancy for an activities organiser. The staff said that they were unable to provide any social care and residents said how they miss this part of life at the home. Comments included, “I used to enjoy the bingo sessions but they have stopped”, I have been in the garden once and it was lovely”, “there has been mention of trips out but none have taken place recently”. One resident said, “there is nothing to do, I am bored”. The manager from the adjoining home confirmed that she was aware of the problems and an activities committee was going to be set up in the near future. The home has an open visiting policy and relatives confirmed that they are able to visit at any time and are always made welcome. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The complaints procedure within the home is not always followed which results in residents concerns and views not being listened to or acted upon. Arrangements for protecting residents are not satisfactory placing them at possible risk of harm. EVIDENCE: The home has policies and procedures available which set out how and to whom complaints may be made. No complaints have been received by CSCI since the last inspection. On the day of inspection there were numerous complaints made by the residents about the lack of hot water for bathing and washing for some considerable time. The staff confirmed that this was an ongoing complaint. The managers of the home were unaware of this ongoing complaint. Following further investigation by the inspectors the home was issued with an immediate requirement and rectified the problem within the timescales. The home has policies in place to protect residents from abuse. The staffs’ training files were not up to date and there was no evidence that the staff have received the company’s in house training or that external training following the local authority procedures have taken place. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,24,25,26 The home was not being well maintained and there were hazards to the health and welfare of residents, staff and visitors. EVIDENCE: The location and layout of the home is suitable for the residents who live there. There are communal lounges and dining rooms on each floor, which were welcoming, well presented and furnished. This inspection took place over two separate days as there were serious concerns raised on the first day which affected the health, safety and welfare residents, staff and other visitors. The concerns raised on the first day are outlined with the action taken by the home on receipt of a serious concern letter. A second visit to the home to complete the inspection found that several of the problems had been actioned. Many of the baths on both floors had their side panels off and these were left propped against the bathroom walls. The assisted Apollo bath and wheel in shower were out if use. The bath thermometers were broken and some bathrooms had no method of Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 15 recording bath temperatures. The non-slip plastic mat was covered with a thick layer of old soap and it was mouldy. Bathroom floorings were wet with pooled stagnant water. The serious problem was with the hot water provision, which was confirmed by testing outlets in bathrooms, en-suites, toilets, sluice rooms and the upstairs treatment room. Staff and residents reported ongoing problems and inconvenience since the beginning of the year. Residents described three-week gaps between baths and this was confirmed from the bathing records. In addition they told the inspector that the water provided for strip washes was often cold. Comments made by residents included “I had a bath yesterday for the first time in three weeks but even then the water was not warm enough”, There is no hot water when I wash at my sink”, It’s murder here-there is no hot water and I can’t have a bath”. Following this discovery the home was issued with an immediate requirement and a serious concern letter. The Company responded within the designated timescales and confirmed that the water pump had been replaced and the hot water supply had been restored. A further visit to the home confirmed that the problem had been resolved and the residents were delighted at having regular baths and were able to wash in hot water. The staff were delighted to be able to fully care for residents and be able to wash their hands in hot water. It was also confirmed that the bath panels had been replaced, bath thermometers had been provided and the plastic non-slip mat had been thrown out. There are a number of other areas that require attention: The en-suites have paper towels but no liquid soap, which prevents the staff from effectively washing their hands. The soap dispenser in bathroom 2 is positioned above an open radiator grill and congealed and dirty liquid soap had built up in the radiator. The lighting levels in the communal bathrooms and toilets were dim with single and bare bulbs lighting the rooms. The sluices on both floors smelled very offensive. The staff were not double bagging used incontinence pads. The light cords were grimy and some had been tied up and several of the mechanical ventaxia units were out of use. The laundry is shared with the adjoining home. The large industrial washer had been out of use for some considerable time and a drier out of use for two weeks. The staff reported difficulties with backlog and build up of soiled and wet washing. The hot tap at the laundry hand washbasin had to be manipulated and held in position to obtain a water flow and any hot water. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 16 Several of the bins had no lids. The chair of the sitting scales was ingrained with grime. The dining room chairs are worn and none have arms or slide and glide rails. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The deployment of staff at peak times is not sufficient to meet the assessed needs of the residents. The recruitment procedures are satisfactory and offer safeguards to protect residents living in the home. The lack of training for staff over a period of time could have a detrimental effect on the care provided for individual residents. EVIDENCE: The home has benefited from having a core staff team who have worked together for a considerable time. There has been a reduction in the staffing levels, which were agreed with the previous regulatory authority. The staff described the serious difficulties they were finding with the reduced levels. They said they felt quality was being compromised and only basic care needs were being met. They were finding the long stretches of duty were leaving them exhausted and still tired after their days off. The nurse call system rang frequently and for long periods during the course of the first visit to the home and staff were under pressure to answer calls and meet requests for assistance. The staffing levels are: Two qualified general nurses 8am to 8pm Six care staff 8am to 2pm Four care staff 2pm to 8pm One qualified general nurse 8pm to 8am Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 18 Three care staff 8pm to 8am. There are two domestic staff on duty during the week and only one domestic on duty at weekends. The home has laundry, maintenance, administration and kitchen staff. The home does not have an activities person. The home has been without a Registered Manager since October 2004.The manager from the adjoining home is currently overseeing Swan Lodge The home has comprehensive policies and procedures for the selection and recruitment of staff. Evidence from a sample of files showed that 2references,Criminal Record Bureau checks, proof of identity and medical questionnaires are completed. The NVQ training is on hold for the time being. Several staff have been attempting to complete training but have experienced delays and change of assessors. The staff training files are not up to date. Staff have not received the required statutory or specialist training to meet residents assessed needs. Samples of the files show that, historically, there were satisfactory training systems in place. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36,37,38 Without a Registered Manger there is no leadership, guidance and direction to staff to ensure residents receive consistent high quality care. This results in some practices that do not promote and safeguard the health safety and welfare of the people using the service. EVIDENCE: The home has been without a Registered Manager since October 2004.There is a deputy manager however her management experience is limited and she has focused on nursing and clinical care of the residents. The residents, staff and relatives made positive comments about the staff team, however they were unclear about what is expected and the care practices being different between shifts, Staff said that they did not receive supervision and the records showed that supervision was not up to date or accurately recorded. Many of the records were not readily available and the filing systems were Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 20 haphazard and disorganised. Some of the records, which were asked for on the day, had to be forwarded after the inspection on the first day. The major concern on the first day of the inspection was the lack of hot water in the home, which impacts on the health, safety, and welfare of residents, staff and visitors. The company responded within given timescales to the immediate requirement and serious concern letter. The problems with the lack of hot water were not notified to the commission at any time from January to May 2005. Other concerns which have now been resolved were The fridge in the upstairs activities room had been switched off and when opened was rancid and a serious health hazard. The microwave was splashed and filthy with old food deposits. Other issues that need attention are The door to toilet 5 is badly damaged around the outer handle with sharp and rough edges. Fire risk assessments were not up to date nor readily available The risk assessments for the safe use of bedrails was not up to date nor did it follow Health and Safety Guidance. All staff have not had the required fire training. The home has regular fire drills. Other records for statutory training were not available The accident recording was satisfactory and there are plans to implement a monthly analysis of accidents in the home. The service records for the Apollo Baths and Hoists were not available on the first day of the inspection. They were posted to the CSCI office as required. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 1 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 N/A 15 N/A COMPLAINTS AND PROTECTION 2 3 2 3 N/A 3 2 2 STAFFING Standard No Score 27 2 28 N/A 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 N/A 1 1 1 N/A N/A N/A 2 2 1 Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 2 Regulation 5. Requirement The home must provide a statement of terms and conditions(or contract) if self funding. THIS IS AN OUTSTANDING REQUIREMENT. The residents must have a comprehensive care plan based on the Care Management assessment and a homes assessment to ensure their needs in respect of healthand welfare are met. The care plans must set out in detail the action staff must take to ensure all aspects of the health,personal and social care needs of residents are met. The care plans must be reviewed at least once a month,updated to reflect any change in need. Risk assessments must be reviewed and up dated monthly. The care plans must be signed by the servive user or their representative. THIS IS OUTSTANDING. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 23 Timescale for action 1st August 2005 2. OP 3 14,15 1st August 2005 3. OP 7 13,15 1st August 2005 4. OP 8 14 5. OP 12 4,12,16 6. OP 16 17 22 7. OP18 12,13 8. OP21 23 9. 10. OP 22 OP 25 16,23 23 11. OP 25 23 12. 13. 14. OP 26 OP 26 OP 26 12,13,16, 23 12,13,16, 23 12,13,16, 23 The care plans must include records of specialist health care in regard to nutrition.with records kept and action taken. Up to date information must be circulated to all residents in formats suited to their capacities. The home must be given the opportunities for leisure and recreational activities both with in and outside the home. The home must record all complaints made by residents and staff about the operation of the home including all investigations and action taken. The home must provide training for all staff to prevent residents being harmed or placed at risk of harm or abuse. The home must ensure that all bath panels are correctly fitted. The flooring in the shower room needs cleaning,the radiator requires cleaning and the soap dispenser relocating. The ventaxia units require repair. The emergency call cords must reach skirting level. The home must ensure that the lighting meets recognised standards of 150 lux and provide suitable light shades in bathrooms and toilets. The home must ensure that there is a constant supply of hot water which provides water close at 43C with records kept. All light cords and emergency call cords require sheathing to enable easy cleaning. The laundry equipment must be repaired or replaced and the hot water tap repaired. The sluice rooms must be regularly cleaned and the clinical 1st August 2005 1st September 2005 1st August 2005 1st September 2005 1st August 2005 1st August 2005 1st August 2005 1st August 2005. 1st September 2005 1st July 2005 1st July 2005 Page 24 Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 waste suitably bagged. 15. OP 26 12,13,16, 23 18 The waste bins in bathrooms and toilets require lids. The sitting scales require cleaning The home must ensure that at all times there are suitably compedent staff working at the home in such numbers as are appropriate for the health and welfare of the residents. The home must ensure that staff have individual training and development files which contain details of all training provided. THIS IS OUTSTANDING. The home must ensure that suitably qualified 1st level nurse is recruited as manager. THIS IS OUTSTANDING. The management of the home must have systems in place to ensure there is a clear direction and leadership for staff to follow. The home must ensure that formal supervision takes place at least 6 times a year with records kept. THIS IS OUTSTANDING. The home must ensure that individual records and home records are secure,up to date and in good order,and are constructed,maintained and used in accordance with the Data Protection Act and other statutory requirements. The home must ensure that staff receive stututory training at the required intervals . The fire training for day staff must be six monthly and training for night staff three monthly. The fire risk assessment must be updated and incorporate an Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 25 1st July 2005 1st July 2005 16. OP 27 17. OP 30 18 1st August 2005 18. OP 31 9,10,12 1st September 2005 1st September 2005. 1st September 2005 1st September 2005 19. OP 32 12, 20. OP 36 18 21. OP 37 15,17 22. OP 38 12,13,23 1 st August 2005 23. OP 38 13,23 24. OP 38 13,23 25. OP 38 17,37 evacuation policy following the advice from the Fire Officer. THIS IS OUTSTANDING The home must ensure repairs are affected to the bathroom 5 door. The home must provide suitable dining chairs to ensure residents safety. The use of bed rails must be identified in individual care plans with comprehensive risk assessments available following the advice of the MDA Agency. The home must inform the Commission of any occurance in the home which is detrimental to the health,welfare or safety of residents,staff or visitors. 1st September 2005 1st July 2005 1st July 2005. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP 19 OP 26 OP28 Good Practice Recommendations The home should consider providing suitable perimeter fencing to reduce the problems of criminal damage. Liquid soap should be provided in all resident rooms to anable effective hand washing. The home should progress with NVQ level 2 training. Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Swan Lodge B53-B03 S28821 Swan Lodge V222956 050505 Stage 4.doc Version 1.30 Page 27 - 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!