Inspection on 25/05/05 for Swanborough House

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 19 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 10/11/05

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 Unannounced 25 May 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 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 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 (PD) registration, with number of places Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service users accommodated will be disabled due to an acquired neurodisability. 2. The service users accommodated will be between 18 and 65 years of age. 3. The maximum number of service users to be accommodated is 31, one of which is respite care. Date of last inspection 13 October 2004 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 H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 25th May 2005 over a period of 8 hours. This forms part of the annual inspection process for this home and was undertaken by two regulation inspectors. The acting manager, Mr Tom Druitt was present and assisted during the visit. During the course of the visit 18 residents and 11members of staff were spoken with. What the service does well: What has improved since the last inspection? The home has improved its record keeping with regard to the resident’s money. There is a new manager in the home who showed a commitment to the welfare of the residents in his care and plans further changes to improve their quality of life. He has an interest in promoting staff training and development, which appears to have improved staff commitment towards the home, and there is a more relaxed atmosphere within the home. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 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 H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 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 standard(s) 1,3, Although there is a range of documentation relating to the services and facilities of the home, not all current residents are aware of these. Further work is required on the care plans to ensure that all assessed needs of the residents are being met. EVIDENCE: The home provides a statement of purpose and service user guide. Amendments to the statement of purpose relating to the satellite homes provided by the organisation, must clarify that these are not part of the CSCI registration of Swanborough House and therefore not subject to regulation and inspection. Not all residents consulted were aware of the provision of service users guide and statement of purpose, but felt that they could ask about any services or facilities, however all residents must be in possession of a service users guide and the statement of purpose should be kept in a prominent position where it is accessible to all residents and visitors to the home. The manager states that the format of the homes literature can be easily adapted to meet some resident’s needs, ie on cassettes- this must be undertaken for a particular resident as a matter of priority. The inspectors discussed the suitability of one placement with the manager and in line with previous requirements this placement had been reviewed by the contract agency and the manager reported that the review concluded that Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 9 this placement does meet the assessed needs of the resident at this particular time, but must be kept under review. The home is unable to fully evidence that it is able to meet the assessed needs of all residents as further work is still required to the care planning process. Most residents spoken with felt that most of their needs were being met by the home. It was seen that residents appeared relaxed and comfortable within the home and in their interactions with staff. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9, The current care planning system does not identify all the needs of the resident, and there is no evidence of resident involvement. Residents are encouraged to take reasonable risks as part of an independent lifestyle. EVIDENCE: The manager reported that a new system of care planning was being undertaken with a view to ensuring that care plans include all the information necessary to guide staff on the assessed health and welfare needs of the residents. Therefore care plans were not looked at in depth on this occasion. The manager must ensure that these are reviewed at intervals dictated by NMS 6 or more frequently if needs change. None of the residents spoken with felt that they were aware of their care plan or had been involved in its development. Therefore during the implementation of the new care plans the manager must ensure that full involvement of residents is included and evidence provided that this has been done. The home was previously required to ensure that where restrictions are placed on service users handling their own personal monies, that this is clearly documented and reviewed frequently. This has not been met and is still Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 11 required to ensure that residents are actively involved in decisions that effect their lives. Residents stated that there was flexibility in the daily routines, namely that of rising and retiring. Staff were observed using alternative methods of communication to offer choices and to help residents make decisions regarding activities of daily living. Residents are encouraged to maintain independence and take part in life outside the home and take reasonable risks, however the home should ensure that the individual risk assessments reflect this. Residents stated that residents meetings have taken place in the past and that these were valued and considered that these enabled them to participate in the running of the home. They also stated they would like to see these occurring more frequently. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15,17 Opportunities are available for residents to maintain and develop social independence and living skills, however outside variables such as staffing levels can impact on this. The meals are good offering choice and variety and catering for special dietary 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, however residents stated that some of the rehabilitation sessions are often cancelled due to staffing absence and staffing levels. ie art therapy sessions cancelled due to staff absence or group and one-to one sessions cancelled due to staffing levels. Residents are able to go out independently, have visitors when they wish and integrate into the local community. Information on local events and activities were displayed and one resident was involved in a fete at Brighton racecourse supporting an animal charity. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 13 The home was previously required to identify their policy on providing holidays for residents including the arrangements for funding, this has not been met and has been made a further requirement. Residents spoken with were not aware of any holiday plans for this year. People do have the opportunity to partake in a range of activities, dependant on their personal finances and one resident spoke of their recent visit to the cinema with their key worker. The home has a minibus which is used to support some residents to access various amenities outside the home which are important to their care, residents and staff stated that the minibus was becoming increasingly unreliable and often needed to be pushed to start. The manager reported that they are aware of this issue but is undecided over what action will be taken regarding this. There is a range of in-house activities including cooking, weekly shopping trips and in-house equipment for entertainment. A new cook is now employed in the home who appears very enthusiastic and knowledgeable about the catering needs of the residents. On the day of the visit she had prepared numerous alternatives to the main meal on offer following requests received from residents. Much emphasis is placed on fresh, organically produced food and a varied menu is offered. All residents with the exception of one, spoke positively about the food provided. Comments received by one resident were passed onto the manager and he was prepared to address these. The cook reported that there are plans to refurbish parts of the kitchen, there was a cleaning schedule in operation but it was noted that the kitchen requires a deep clean. The freezer lid was in need of repair and this should be in the schedule of maintenance required. Catering staff were in possession of their food hygiene course and there was evidence that all records required to be kept for food safety were up to date. Within reason mealtimes were flexible to allow for the individual programmes and preferences of residents. On the day of the inspection the meal served looked plentiful and appetising and staff were observed offering discreet and sensitive support to those who needed it. A recommendation has been made that the menu is displayed in order to promote choice and aid orientation. Specialist diets were catered for in an appropriate manner. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,21 Residents stated that the personal support they receive is provided in a manner which is appropriate to their needs. EVIDENCE: Residents felt that the support provided by staff was appropriate to their needs and respected their privacy and dignity. Residents have two key workers in order to promote continuity of care and this was highly valued by residents who were all able to name their key workers. A previous requirement was made asking for the review of the suitability of the use of listening devices. This has been undertaken and in order to ensure that human rights are protected, agreed individual guidelines must be put in place. Although on this occasion care plans were not able to be fully examined, residents identified that they felt their needs were met. Residents stated that there was not always hot running water available when it was required, discussion with staff identified that there had been problems around the hot water boiler. This must be addressed as part of the maintenance plan. The CSCI pharmacy inspector is undertaking a separate inspection of medication and their findings is recorded separately from this inspection. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 15 The home has had a resident die recently and staff spoke sensitively about the support provided by themselves and healthcare professionals. Staff were offered personal support following this. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has a satisfactory complaints system with some evidence that residents feel that their views are listened to and acted upon by the manager. Adult protection training and procedures have improved since the last inspection, further work is still required to ensure that residents safeguarded by the homes recruitment practices. EVIDENCE: The complaints procedure currently in use requires some amendments to identify persons to whom complaints should be made including the details of the commission, and should make it clear that all service users or their representatives can make complaints to the commission. A new complaints form for recording complaints has been formatted and some staff have attended training on handling complaints. It is considered good practice to have a copy of the complaints procedure on display in order to enable visitors to the home and residents to have easy access to this. It is recommended that verbal minor concerns made to the manager are recorded including the action taken to rectify this, this will enable the manager to be able to evidence his actions when these occur. Residents and staff stated that they felt confident and comfortable to approach the manager with any concerns or complaints that they may have. Training on protecting the vulnerable adult forms part of the in-house training programme and staff spoken with understood their responsibilities in this. Most staff were aware of the whistle blowing policy, but it is recommended that further training around this takes place Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30.The home provides a comfortable environment which although needs redecoration in some areas meets the needs of the residents. EVIDENCE: The home is situated in a residential area of Brighton with good access to local amenities and transport. Overall standards of maintenance and decoration are good, however some communal areas are now in need of urgent redecoration and refurnishing. Some chairs in the lounge area need replacing and should be provided in a variety of heights and styles to accommodate resident’s needs. Some carpeting is in poor condition and the dining area is in particular need of refurbishment, for examples tables are kept stable by paper wedged under their legs. The overall décor of the dining room gives an institutional feel. All bedrooms were seen to be personalised to reflect 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. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 18 Some bedrooms are still not provided with a locked facility and one room does not have a lockable door. Residents spoken with stated that they were happy with their rooms and felt they lived in comfortable surroundings. Previous inspections identified that new bedding towels and flannels were needed, a requirement was made on this and has now been met. However the requirement to provide privacy in some bathrooms and toilets has not been met although some action was taken by fitting additional privacy film over the frosted glass, this does not provide adequate privacy for residents and must now be addressed as a matter of urgency. There is evidence that the home provides a range of individual aids and adaptations to assist residents mobility and independence. However the portable call bell facility had been removed in the top floor bathroom and this is the second occasion that this has been noted. The manager must address this to ensure that a call bell facility is always accessible. All areas seen, with the exception of the kitchen were found to be clean and free from offensive odours. In order to address the redecoration and maintenance issues highlighted in the inspection, a maintenance and redecoration plan has been required to be sent to CSCI. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36. Residents benefit from a well trained staff who have a good knowledge base which enables them to give support to the residents. EVIDENCE: Staff showed a good understanding of the boundaries of their role and the purpose and function of the service. Staff are divided into two teams therefore supplying a continuity of care, carers are supported by team leaders and a care co-ordinator. Concern was expressed that some staff are undertaking invasive procedures outside of the normal care assistant role and although they have been assessed to do this, there is a query over accountability, which is being addressed by the CSCI pharmacy inspector and is included in the letter to the home, ref Lpharms 1426SC090506 .Some staff stated that they were concerned about the number of staff administering medication. The home is very committed to providing opportunities for staff training and development and this includes accessing NVQ and a range of core and specialist training. Individual training records are now put in place and there is a designated training co-ordinator. Recently recruited staff undergo a comprehensive induction which specifies areas of training to be covered in the initial stages of employment. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 20 On the day of the visit there were ten staff on duty in addition to the ancillary staff and manager. Staff however, express concern that this staffing structure did not always enable them to fully meet the needs of the residents and undertake their key worker duties, and at times resulting in them not being able to spend individual time with residents this is particularly apparent if staff sickness or absence occurs. The manager states that he is able to increase staffing levels and cover shifts when he feels it is appropriate without having to seek permission from the provider. However staff also stated that there are not enough staff on at night and felt it needed to be increased by one. The manager felt that there were sufficient staff on duty but is prepared to address this with staff. There was good interaction seen between staff and residents and residents stated that staff were ‘caring’, ‘considerate’, ‘nice and friendly’. A sample of personnel files were examined, these revealed that some staff have been employed without having a CRB or POVA check prior to their commencing duties. This compromises resident safety and a requirement has been made around this. The manager has introduced formal regular supervision sessions which take place within timescales identified in the standard. It was identified that various topics are addressed within supervision which enabled the manager to assess standards of care and staff concerns. Staff stated that they feel well supported by the manager and team leaders. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40,41,42,43 Significant steps have been taken to ensure that there is an open and transparent management system in place, and residents and staff appear to be benefitting from this sense of leadership and direction. Steps need to be taken by the provider to facilitate the new manager to gain control over all aspects of managing the home. EVIDENCE: A new manager, Mr Tom Druitt, has been in post for two months, previously having worked at the home as a team leader. He was open and helpful throughout the day. All residents and staff spoke very highly of Mr Druitt with particular reference to his focus on resident’s welfare. He has produced a document ‘Looking ahead’ for staff and residents which provides a clear sense of leadership and direction for the future. However it is not always clear that he is able to fulfil all Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 22 of the managerial responsibilities due to constraints placed on him due to limited decision making powers at this stage of management career. It is however recognised that he is at present on management induction, but for the future it will be necessary that he is given increased control of business planning, budget control and decision making within the home. The registered provider, although frequently visiting the home to offer support to the manager, is not compliant with his responsibilities under regulation 26 and this is expected to commence. However some staff have expressed concerns relating to their terms and conditions of employment and felt that this was the contributing factor leading to moderate staff turnover. Staff meetings have been held and these will be continuing. There is a comprehensive policies and procedures manual. These have been recently reviewed to reflect development in practice and staff sign to say that they have read these. Significant improvements have been made to address previous concerns noted around resident’s personal monies. However it was not possible to audit all financial records relating to residents where the registered provider acts as corporate appointee, as these records were not kept within the home. This was a previous requirement and remains unmet. This must be addressed as a matter of priority. There were few records in the home to identify that the servicing of utilities and equipment has taken place. These include the IEE record, landlords gas certificate, lift certificate, hoist servicing and no records of weekly testing of fire alarms. Confirmation that these matters have been attended to must be sent to the CSCI. The majority of staff have received mandatory training including fire training and manual handling training. A requirement made around fire safety in the last inspection has been met. Residents stated that sometimes hot water was not available for washing and this must be addressed in the maintenance plan which should identify the need for regular servicing of the boiler. Staff have expressed concerns that the current storage arrangements for wheelchairs on the ground floor often present a safety hazard, a recommendation has been made around this. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x 2 x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 3 2 3 Standard No 11 12 13 14 15 16 17 3 2 3 2 3 x 3 Standard No 31 32 33 34 35 36 Score 2 3 2 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Swanborough House Score 3 x x 3 Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 2 2 2 H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 24 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. 2. Standard YA1 YA6 Regulation Reg 6 (a) Requirement Timescale for action July 30th 2005 July 30th 2005 3. YA22 4. YA 24 5. YA24 6. YA27 7. YA34 That amendments are made to the statement of purpose as discussed with the manager. Reg That risk assessements should 13(4)& be completed and regularly 15(1) reviewed.( This was a previous requirement and has been followed in part, due date 30th Nov 2004) Reg 22(8) A record of complaints must be kept.( This was a previous requirement with immediate effect) Reg That a lockable facility is provded 13(2)& in all bedrooms ( This was a 23(2)(m) previous requirement 30.12.04) and that a lock is provided on one service users door. Reg That all parts of the home are 23(2)(a)to maintained in good decorative (d) order.( This was a previous requirement. 30.01.05) A plan of redecoration and repair to be developed and a copy forwarded to the commission. Reg That measures are put in place 12(4)(a) to ensure service users have privacy when using bathrooms.( This was a previous requirement 30.11.05) Reg 19 No person to commence working H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc July 30th 2005 July 30th 2005 August 1st 2005 Immediate Immediate Page 25 Swanborough House Version 1.30 Sched 2 8. YA39 9. YA42 10. YA14 11. YA6 12. YA16 13. YA41 14. YA33 at the home until all documentation including the POVA and 2 written references are obtained. Reg 26 The registered provider to visit the home and supply reports to all persons and CSCI as detailed in this regulation. Reg 23(4) That service users receive clear printed instructions on what action they must take in the instance of fire.Service users should be included in fire drill training within the home. Reg The registered provider must 12(1)&20( clarify in writing the homes 3) policy on providing and funding holidays for service users and this must be included in the statement of purpose and service users guide.( This was a previous requirement 30.12.04) Reg 15(1) The registered provider must ensure that all service user plans are comprehensive ,providing staff with detailed guidance as to how to meet service users needs.( This was a previous requirement 30.12.04) Reg The registered provider must 17(1)(a) ensure that where restrictions Sched 3 are placed on service users (3)(q) handling their own personal monies, this is clearly documented and is reviewed frequently. ( This was a previous requirement 30.11.04) Reg 17(2) The registered provider must Sched ensure that records relating to 4(8)(9)(a) the management of service users personal finances, where the provider acts as corporate appointee are available for inspection at any time.( This was a previous requirment 30.11.04) Reg The registered provider must 18(1)(a) review staffing levels to ensure that there is sufficient number of H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc July 30th 2005 July 30th2005 July 30th 2005 Aug 30th 2005 July 1st 2005 Immediate July 1st 2005 Page 26 Swanborough House Version 1.30 staff on duty at all times. 15. YA 30 Reg 23(2)(d) & Reg13(3) Reg 12(4)(a) Reg 23(2)(c ) Reg 23(2)(n) Reg 5(1)(2) Reg 15(2) That regular deep cleaning of the kitchen is undertaken. That individual guidelines on the use of listening devices be implemented. That the roller iron is repaired. July 1st 2005 July 1st 2005 16. 17. 18. YA23 YA30 YA29 19. YA1 20. YA6 21. 22. 23. YA24 YA 20 YA 20 Reg 23(2)(c ) Reg 13(2) Reg 13(2) July 1st 2005 That a call bell with an accessible Immediate alarm facility is provided and accessible in the top floor bathroom. All service users must be given a July 1st copy of the service users guide 2005 in a format necessary to meet their needs. Unless it is impractical to do so Sept 1st service users are consulted 2005 regarding the development and review of their care plan and are notified of any revision to the plan. Where possible service users signatures or those of their representatives must be included. That the suitable provision is in Immediate place to ensure that hot water is available at all times. To review medicine Aug 2005 administration process. To provide appropriate training Aug 2005 with documentation for special technique medicine administration and have fully documented detailed procedure for each such action within the care plan. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 27 No. 1. 2. 3. 4. 5. Refer to Standard YA22 YA 29/YA42 YA 17 YA22 YA 20 Good Practice Recommendations That the complaints policy is displayed in a prominent postion to ensure that service users and visitors are able to identify to whom complaints should be made. That wheelchairs and hoists are stored appropriately at all times. That the days menu be displayed in an appropriate format for service users. That minor concerns raised by service users verbally are recorded including the action to ensure that these are being addressed. To check for interactions with conventional medicines when alternative therapies are used. Swanborough House H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection 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 H59-H10-S14246 Swanborough House V222797 250505 Stage 4.doc Version 1.30 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. 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. 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