Inspection on 10/11/05 for Swanborough House

This inspection was carried out on 10th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Swanborough House 08/05/07

Swanborough House 10/05/06

Swanborough House 25/05/05

Swanborough House 13/10/04

Swanborough House 27/05/04

Swanborough House 18/07/02

Similar services:

Thorndene

Sutton Lodge Nursing Home

Wingham Court

Bethany Lodge

17 John Street

Red Oaks

Clare House Nursing Home

Broad Oak Manor Nursing Home

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

CARE HOME ADULTS 18-65 Swanborough House Swanborough Drive Brighton East Sussex BN2 5PH Lead Inspector Elizabeth Dudley Announced Inspection 10th November 2005 10:00 Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 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 Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Swanborough House Address Swanborough Drive Brighton East Sussex BN2 5PH 01273 696391 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) Raphael Medical Centre Limited Vacant Care Home 31 Category(ies) of Physical disability (31) registration, with number of places Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is thirtyone (31), one of which is respite care. Service users must be aged between eighteen (18) and sixty-five (65) years on admission. The service users accommodated will be disabled due to an acquired neurodisability. 25th May 2005 Date of last inspection Brief Description of the Service: Swanborough House is registered to provide accommodation and personal care to 31 adults who have disabilities due to acquired brain injury. The home aims to provide a range of therapies and activities designed to promote rehabilitation. The registered provider is the Raphael Medical centre and the responsible individual is Gerhard Florschutz. The home follows the Rudolph Steiner philosophy of holistic living and all catering and therapies offered follow this philosophy. The homes literatures states that its vision is to develop and provide a residential rehabilitative unit and day care facility for adults with acquired brain injury, based on the Anthroposophic image of man as a being of body and spirit The home is located in Brighton with access to local amenities, which include the Whitehawk community centre. Public transport routes serve the area. The home consists of single rooms, most of which have ensuite facilities and there is a range of communal space which includes a dining room, lounges and a large rear garden. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was undertaken by Elizabeth Dudley and Jane Jewell, Regulation Inspectors, on the 10th November 2005 over a period of 7½ hours; it was facilitated by Mr Tom Druitt, acting manager and Dr G Florschutz, responsible individual. During the inspection, which was undertaken by two regulation inspectors, staff and residents were spoken with, a tour of the home took place, care plans, medical and training records, personnel files, menus and health and safety documentation was examined. What the service does well: What has improved since the last inspection? Significant progress has been made towards meeting areas of concern noted at the last inspection. This has improved the standard of record keeping, some parts of the environment, residents safety and financial management. There is considerable improvement in the leadership and direction which has improved staff morale and this has positive implications for the care of the residents. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 The home provides sufficient documentation relating to the services and facilities, including staff training, to enable prospective residents to be assured that the home will meet their assessed needs and goals. EVIDENCE: A statement of purpose and service users guide, which meet the standard, are in place, all residents have a copy of the service users guide. Staff showed a clear understanding of the aims and objectives of the home. In the last report it was stated that the service user guide was required to be put on cassette for one specific resident, this resident now says that he does not wish for this to happen. However in view of the various disabilities of the residents admitted to the home, it would reasonable for the home to keep some copies of the guide on cassettes for resident’s use. Care plans identified that specific goals and needs of the resident were identified on admission, and residents spoken with confirmed that their needs were being met by the home. Staff training plans showed that staff receive specialist training both on the ethos of the home and the specialist requirements of these residents and that the prospective residents can be assured that the home will work to meet their goals and will be aware of present and changing needs. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 9 All residents are assessed prior to admission and are encouraged to visit the home and meet staff and residents and all prospective residents are admitted on a month’s trial period. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,The arrangements for planning care are good, ensuring that health, personal and social care needs of residents are met. EVIDENCE: Four residents were case tracked and their specific care plans examined which it was felt would be representative of all the care plans. These were all found to evidence the resident’s involvement in the care plan, had been reviewed regularly and were comprehensive in addressing the assessed needs of the resident. There was clear evidence that residents needs were regularly reviewed and that input from a multidisciplinary team at the home was included. Resident’s goals, and how they are assisted to achieve these, were identified in the care plans, together with appropriate risk assessments. The therapies given to residents were identified, as well as the amount of participation in the life of the home that they were able to achieve. Residents spoken with said that they felt they were able to choose what therapies they took part in and that they had choices around their activities of daily living. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 11 Where decisions have been made regarding restrictions on a resident’s lifestyle, it must be clearly evidenced and documented on how this was reached and the level of involvement by the resident in this decision. Staff were observed supporting residents with communication difficulties to make choices to determine their daily routine. All care plans were seen to be very individually focussed, with the aspirations and choices of the resident guiding the care given. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 – 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Residents are encouraged to develop skills that will enhance their opportunities to lead an active and fulfilling life within the range of their needs. EVIDENCE: Residents are encouraged to develop skills that will enhance their opportunities to lead an active and fulfilling life and participate more actively in wider society. Emphasis on personal development and rehabilitation is at the core of the home’s ethos and this is reflected throughout care plans and documentation within the home. Staff are aware of their importance in their role of promoting the independence and individuality of residents and enabling them to lead an active and fulfilled lifestyle within the constraints of their individual limitations. Active rehabilitation programmes in house include art therapy, speech therapy and physiotherapy. An occupational therapy kitchen is on site and used for individual and group cooking sessions. The rehabilitation assistants hold sessions on a daily basis on topics including current affairs, concept skills, nature appreciation, and other relevant sessions. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 13 It was noted that the programme for those residents on a ‘slow stream’ rehabilitation programme was tailored differently to the programme of shortterm care therefore preventing boredom through familiarity. Sessions held away from the home include computer skills, woodwork and swimming and those resident who are able take part in the normal social life within the community of the area. There are a variety of arrangements for holidays, one resident is holidaying abroad at present, and a holiday cottage booked for others. Some residents recently took part in a day trip to the Isle of Wight, many residents spoke of other leisure activities they are involved in including visiting cinemas, local cafes and pubs, walks, dog racing and horse racing. Residents are encouraged to maintain contact with family and friends and visitors may visit at any time and residents stated that their visitors are always made to feel welcome. Although the home’s own transport is undergoing repair at present, this had not affected access to the external activities. Although there is flexibility in the daily routines the emphasis of the home and its culture is to establish ‘rhythm’, therefore residents have an individual daily programme to help them establish this in their daily routine. Residents agree their individual timetable with their key worker and spoke of the weekend being used to undertake spontaneous activities and events. The catering staff continue to be enthusiastic and innovative relating to the provision of food. Several options were seen to have been prepared for the lunch on that day with residents being made aware of these by the staff taking menu cards to each resident and their choices recorded. Records of meals provided are kept for the prescribed amount of time. Emphasis is placed on fresh, organically produced food, all residents spoken with, made positive comments on the food and the variety of choices offered. Some refurbishment has taken place in the kitchen and regular cleaning of the kitchen is evidenced by a cleaning schedule, the staff report that high cleaning is now done by them under the auspices of a risk assessment. The home has recently had its ‘clean food award’ renewed by the Environmental Health Department. There was a good supply of fresh, frozen and dried food. and records of fridge, freezer and hot food temperatures were in place showing these to be within recommended parameters. All catering staff are in possession of a food hygiene certificate. Where feedback has been received from residents regarding catering, it was clear that this has been acted on promptly by the manager. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 14 Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 The blend of alternative and conventional medicine is central to the ethos of the home in addressing the holistic needs of the residents. EVIDENCE: The personal support needs of each resident were fully documented in the care plans; this gave clear guidance for staff on supporting the resident with personal care. Residents identified that their privacy was respected during personal care and one resident stated that “ staff never rushed the care”. Each resident is allocated two Key Workers, which supports the continuity of care making residents feel secure. All residents are registered with a General Practitioner, and an Anthrosophical doctor visited the home regularly. All residents stated that requests to see their GP were actioned promptly. Several residents confirmed that specialist nurses also visited the home, including CPN’s. The standard of medication administration has improved. In line with previous requirements MAR charts are now taken around with the medication and signed immediately. The home conducted a study regarding the efficiency of using a medicine trolley in this environment and stated it was too time consuming. Although this Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 16 would be the safest method of administration, providing the method used at present is consistently applied, risks to residents will be minimised. The care manager was able to evidence that she had a sound working knowledge of the administration of medication and has undertaken an accredited course, as have all staff involved in this. The registered nurse who provided training in invasive medication administration procedures must provide written evidence of accountability. There was evidence of stock rotation, records of fridge temperatures and awareness of the recording requirements of Controlled Drug administration. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The manager can evidence that he addresses all complaints, both written and verbal and keeps secure records of these. Staff were aware of their responsibilities towards the protection of those in their care. Residents can be confident that their complaints are taken seriously, and that staff have sufficient knowledge to ensure their safety. EVIDENCE: There is a complaints procedure, which meets this standard; copies of the procedure are displayed in the home and in the service users guide. Any complaints received are addressed within 28 days and copies of all correspondence and outcomes are kept in a confidential file. The manager stated that the majority of residents make their complaints during resident’s meetings on a verbal basis, and he was able to evidence that written summaries of these complaints were kept and that the complaints had been addressed. Staff felt very comfortable in approaching the manager with any concerns they may have. The majority of staff have received training in the protection of the vulnerable adult and were aware of their responsibilities of those in their care. Staff spoken with were aware of the ‘whistle blowing’ policy and also of which outside agencies to contact should they need to do so. Risk assessments address the actions to be taken to protect any resident who may have a history of self-harming, and care plans provide comprehensive histories and details of any triggers that may precipitate this. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 18 There was also a clear policy on action to be taken in the case of a resident’s unexplained absence from the home, and evidence has been provided that staff followed these procedures effectively in this situation. It was previously required that individual guidelines on the use of listening devices be implemented, this is to ensure that human rights are protected and staff are aware of when these devices should be used. This had not been undertaken. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 The standard of the environment is generally good, providing residents with a comfortable place in which to live. Further redecoration is needed to ensure consistent standards throughout. EVIDENCE: Overall standards of maintenance and decoration remain good. However in order to address the minor redecoration and maintenance noted at the inspection (and discussed with the manager and provider), it has been required that a schedule of maintenance and redecoration to address these areas, including the timescales allotted, be submitted to the CSCI. This has now been received, but only addresses 2005. It is anticipated that a further maintenance plan for 2006 will be in place Actions have been taken to address previous concerns around décor, which includes a new carpet in the lounge and variable height chairs provided. Problems previously noted relating to the dining tables, appear to have been addressed but attention should be given to creating a more homely feel to the dining area, and this must be addressed in the maintenance schedule requested. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 20 It was previously required that suitable provision is in place to ensure that there is hot water available at all times, despite regular servicing of the boiler the home was without hot water for a couple of days. This was reported that this was due to human error. The manager must ensure that the person in charge is aware of the emergency procedure to be taken and the need to promptly report such occurrences to the manager or provider. All bedrooms continue to be personalised reflecting individual residents needs and wishes. Some residents had chosen to bring in small items of furniture and personal belongings; many residents continue to have their own televisions, audio equipment and computers. The standard of decoration is good with particular attention paid to a natural and personal environment. Bedroom doors are fitted with locks and the majority of bedrooms were locked when not in use. It was identified that the lock on one resident’s room was not appropriate, as it did not allow staff to override this in event of emergency, therefore the provision of an appropriate lock was discussed. In line with previous requirements, a further layer of privacy film has now been fitted over frosted glass in some toilets and bathrooms. However, further instances of glass panes in doors not providing suitable levels of privacy were noted. Therefore a further requirement regarding this has been made. There is evidence that the home provides a range of individual aids and adaptations to assist resident’s mobility and independence. All call bells checked were in working order and promptly answered by staff. In order to address the previous concerns around accessibility of a call bell in a bathroom, this call bell has now been affixed to the windowsill, however this has resulted in limited access to the bell and the provider has agreed to obtain an extension cord. The ground floor corridor should be risk assessed to establish the suitability and safety of wheelchair users. All areas were found to be exceptionally clean and free from offensive odours. Since previous inspection the manager has introduced a monitoring system around the standard of bed linen ironing. One example was noted where this had not been implemented effectively and this was fed back to the manager. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 Staffing levels and the standard of staff training enables staff to be able to undertake their roles effectively in accordance with the homes aims to provide rehabilitation for residents. EVIDENCE: Staff had a very clear understanding of the purpose and boundaries of the service and how their role contributed to the achieving of the home’s aims. The home provides a training co-ordinator who implements the home’s comprehensive training schedule. This includes NVQ, mandatory and specialist training. Some of this training has been provided by the organisations training consultant and some by local colleges, and specialist personnel. Staff stated that they received comprehensive induction course and felt that they had sufficient training to undertake their roles. Many good care practices were observed and residents described staff as ‘very nice’, ‘all helpful’, very kind, and ‘I really like my key worker’. Residents stated that staffing levels were sufficient to meet their needs and to enable them to spend individual time with Key workers. The staffing level has been increased in line with previous requirements made, with staff saying that Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 22 suitable provision has been made for the covering of staff that are away on sickness or annual leave. Personnel files evidenced that all documentation was in place as required by Reg 19 and Schedule 2. Staff did feel well supported by the manager. Formal supervision of staff is delegated to the team leaders and in the main had been undertaken at times dictated by the standard. However records were not clear relating to the timescales and it was recommended that a more structured approach was undertaken. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,40,41,42,43. Residents benefit from the ethos, leadership and management approach in the home which ensures that their views are sought and listened to EVIDENCE: The manager, Mr Tom Druitt has now been in post for six months and during this time has made a significant contribution to the improvements in care and staff morale within the home. He is undertaking the Registered manager’s award and is applying for registration with the CSCI. The ethos in the home is more open and transparent and there is a positive atmosphere within the home. This has been noted by staff and residents and they commented upon the strong management and sense of direction now in place in the home. Policies and procedures show evidence of being reviewed and some new policies have been added to the existing manual, notably the ‘Residents holiday policy’ and the ‘medication policy’. These policies are designed to guide and inform staff and are kept in the locked staff office. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 24 The provider acts as corporate appointee for several residents. Records relating to the management of these monies are now available at the home and individual financial assessments have now been developed. These identify the individual arrangements how each resident is to access their money; the majority include the residents signature confirming their participation and agreement. In those cases where the resident has not yet signed the assessment, further evidence is required to indicate their agreement and participation in the process. There was evidence of clarity of record keeping relating to resident personal money held at the money, including copies of receipts and money given to residents. It was identified that bank accounts need to be opened for some residents and the provider gave assurances that this was in progress. All certificates relating to the servicing of utilities and equipment were in place with the exception of the landlords gas certificate. The servicing has been undertaken but the certificate is awaited. The CSCI should be notified when this is in place. Some new staff have not undertaken formal fire training and this must be addressed. The magnet on the fire door on the top floor did not permit the door to remain open; the provider reported that this was in the process of being actioned. Residents were aware of what action to take in the instance of fire, have been included in fire drills and had instructions on their room doors. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Swanborough House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 3 2 3 DS0000014246.V265841.R01.S.doc Version 5.0 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation Reg 13(2) Requirement That records are kept of agreement for accountability in the case of invasive medication procedure. Those individual guidelines on the use of listening devices be implemented. (This was a previous requirement May 2005) That a programme of maintenance and decoration is provided which addresses the areas identified during the inspection and includes timescales for completion. That the suitable provision is in place to ensure that hot water is available at all times. That measures are in place to ensure service users privacy in bathrooms and w.c’s Evidence of agreement with financial assessment be provided. That the manager provides a copy of the Landlords Gas Certificate to the CSCI and fire training is provided to those new staff who have not yet undertaken this. DS0000014246.V265841.R01.S.doc Timescale for action 01/12/05 2 YA23 Reg 12(4)(a) 01/12/05 3 YA24 Reg 23(2)(d) 01/04/06 4 5 6 7 YA24 YA27 YA41 YA42 Reg 23(2) (c) Reg 12(4)(a) Reg 12(2) Reg 13(4) Reg 23 01/12/05 01/12/05 30/01/06 10/02/06 Swanborough House Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. 3 4 Refer to Standard YA1 YA7YA7 YA36 YA29 Good Practice Recommendations That the statement of purpose and service user guide are produced in a audio cassette format for those service users that may require this. That a record be maintained of any limitations agreed with the service user regarding any restrictions around their life style. That a more structure approach is in place regarding the organisation of staff supervision. That the ground floor corridor is assessed for the suitability and safety of wheelchair users. Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Swanborough House DS0000014246.V265841.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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