Inspection on 30/01/06 for Swanland House

This inspection was carried out on 30th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Swanland House 27/11/08

Swanland House 28/11/06

Swanland House 27/10/05

Swanland House 27/01/05

Swanland House 06/09/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Swanland House 41 West End Swanland North Ferriby East Yorkshire HU14 3PE Lead Inspector Ann Day Unannounced Inspection 30th January 2006 14:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Swanland House Address 41 West End Swanland North Ferriby East Yorkshire HU14 3PE 01482 634159 01482 633328 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) Mrs Elizabeth Anne Stevenson Mrs Elizabeth Anne Stevenson Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: Swanland House is a privately owned care home and is a Grade 2 listed building. The home is registered to offer care and accommodation for 20 older people, including those with dementia. The interior and the décor are of a traditional design. There are eight shared rooms and four single rooms. The garden is very pleasant and there is a car park for staff and visitors. The home is close to the centre of the village and local amenities, including a public house, shops, a café and hairdressers. The home is accessible to all service users via the use of ramps, a passenger lift and a stair lift. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over four hours on 30th January 2006. There were 20 service users resident in the home, receiving personal care. The inspection focused on a number of key standards. A tour of the premises took place, including a number of bedrooms, the homes dining room, lounges and bathrooms. The care records of service users were examined in detail and a number of service users were spoken to and asked about the care they receive. There were discussions with, the cook, two members of care staff on duty, the Registered Manager Mrs Elizabeth Stevenson was not on duty, but the home’s senior carer was available throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Medication was not administered as required during the visit. The error once brought to the attention of the member of staff was resolved. Staff files were generally in good order, but one staff file did not include two written references as required, this was brought to the attention of the registered manager. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 6 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. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5,6 Service users’ needs are fully assessed prior their admission to the home, enabling the home’s staff to meet their individual needs. EVIDENCE: Care records of service users were examined. The Registered Manager of the home assesses prospective service users prior to their admission. Service users/relatives are able and encouraged to visit the home prior to admission to meet with staff and see their prospective room before making a decision to come into the home. Information about service users’ health and personal care needs had been documented and information gathered from relatives and other health professionals giving a good picture of the care that needed to be provided. The home does not provide intermediate care. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service users’ needs are met and they are treated with respect and their right to privacy is upheld; however service users were not fully protected by the practices for the administration of medication. EVIDENCE: Care records of residents were found to be well kept and comprehensive. Care plans were detailed; reviews were documented and key workers recorded monthly evaluation of the care provided for each individual resident. All aspects of health, personal and social care needs are addressed. There are comprehensive risk assessments, which are all kept on one file. The home continues to use a “Kardex” system; the Registered Manager agreed to keep the system under review. The home has comprehensive policy and procedures for the safe handling of medication; and members of staff who administer medication have attended training. However, a member of staff proceeded to “pot up medication” at teatime; once the error was brought to the attention of the member of staff, it was resolved immediately and medication for the residents was then administered safely. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 10 Members of staff were seen knocking on bedroom doors and awaiting an invitation before entering. Members of staff were seen to have good relationships with the residents. The home has eight shared rooms and screens to ensure individual’s privacy are provided. A district nurse spoken to during the visit commented that it was a good home and residents’ needs were well met. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users are provided with the opportunity to engage in a variety of activities, satisfying their social, cultural and religious needs. Service users maintain contact with family and friends as they wish; they are helped to exercise choice and control over their lives; and they receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: The home has a comfortable and relaxed atmosphere. Time is spent each day in engaging those service users in conversation or activity who might have difficulty with concentration or who have a deteriorating condition. Weekly outings are organised to which all residents who wish may attend. Notices of activities and outings are posted in residents’ bedrooms. An activities organiser visits the home on a weekly basis and organises exercises, quizzes and games for the residents. Holy Communion is available for the residents monthly, the mobile library six weekly, there are also entertainers who visit the home from time to time. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 12 Those service users who are reasonably independent are encouraged to go out unaided where feasible. Service users, relatives and staff members said and observation confirmed that visitors are made welcome. Service users said they had control over when they got up and went to bed each day, they could choose what they did with their day according to capacity, and said staff would help arrange particular activities. Service users also reported that they enjoyed the food. Preferences, dislikes or allergies are recorded and taken into consideration. Specialist and softened diets are catered for, a four-week menu was available for inspection and the menu was posted on a café board in the dining room. Service users who require help with feeding are assisted in a caring and respectful manner. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 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 the following standard(s): 16,17,18 Service users and their relatives are confident that their complaints will be listened to, taken seriously and acted upon, their legal rights are protected and there are policies and procedures in place to protect them from abuse. EVIDENCE: The home has a comprehensive complaints policy and procedures. Service users and members of staff said that they would have no hesitation in raising any concern with the manager, in the knowledge that she would treat their concerns seriously. The home has not received any complaints since the last inspection. The manager has ensured that every resident has a postal vote, enabling them to take part in local and national elections. The home makes available policies and procedures and local guidance for the Protection of vulnerable adults and staff have attended training. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 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 the following standard(s): 19,21,22,24,25,26 Service users live in a safe, well maintained, clean environment, with their own possessions about them. EVIDENCE: The home is a Grade II listed building, which provides comfortable, homely and attractive accommodation for service users. The home is well maintained and there is a refurbishment and maintenance programme in place. Repairs to the home’s guttering, was being undertaken at the time of the inspection. Furnishings and décor are comfortable, domestic in nature. The home has eight shared and four single rooms; two of the rooms have en suite facilities, sufficient bathrooms are provided for service users, which are adapted for those individuals with mobility problems. The home has two mobile hoists in use. Service users’ rooms are personalised with pictures, photographs and small items of furniture they have brought from home. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 15 The home was clean and fresh smelling throughout and gloves and aprons were in good supply, infection control policies and procedures are in place. The home has a laundry, which is well equipped and located away from the dining area. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Service users’ needs are met by the numbers and of competence and training of members of staff. However they are not fully protected, by the home’s recruitment practices. EVIDENCE: Sufficient numbers of staff were on duty on the day of the inspection to meet the needs of the current 20 residents of the home. The home has robust recruitment policies and procedures, employment checks, Criminal Records Bureau (CRB) checks, are stored separately and securely, and in general staff files were in good order; however one staff file contained only one written reference, this was brought to the attention of the home’s Registered Manager. Training is a priority in the home and members of staff confirmed that they have the opportunity to attend training sessions in addition to induction and NVQ Level 2/3. One member of staff is being encouraged to undertake their nurse training. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, The home is well managed and provides a safe place for service users to live and staff to work. EVIDENCE: Mrs Elizabeth Stevenson, the registered provider/manager has completed the NVQ 4 Registered Manager’s award and has a nursing qualification. Mrs Stevenson was day off during the visit but was available the following day to discuss the inspection. The home has a policy of continual self -monitoring and has a proactive approach to improving the quality of service through consultation and regular review. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 18 All service users manage their own financial affairs or are assisted by a family member or solicitor. Some personal allowances are held by the home. Three records were checked and found to be accurate. All members of staff receive regular supervision, which is recorded. Staff meetings are held every six months, and mentor meetings are held every three months. A member of staff said, “ It’s a really good home, really good support network, can talk and get involved with residents”. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X X Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation Reg. 13(2) Requirement The registered person must ensure that medication is administered safely, as per legislation and national guidance at all times. The Registered Person shall not continue to employ a person to work in the home unless two written references have been obtained. Timescale for action 30/01/06 2 OP29 Reg. 19(b) Sched. 5 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The Registered Manager continues to review the use of a “Kardex” system. Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Swanland House DS0000019730.V278412.R01.S.doc Version 5.1 Page 22 - 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!