Inspection on 22/08/07 for Swanton House Care Centre

This inspection was carried out on 22nd August 2007.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Swanton House Care Centre 02/07/08

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Swanton House Care Centre Dereham Road Swanton Novers Norfolk NR24 2QT Lead Inspector Ruth Hannent Unannounced Inspection 22nd August 2007 09:00 Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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 Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Swanton House Care Centre Address Dereham Road Swanton Novers Norfolk NR24 2QT 01263 860226 01263 863012 siva.armugam@swantoncare.com 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) Swanton Care and Community Ltd Mr Siva Armugam Care Home 43 Category(ies) of Learning disability (12), Mental disorder, registration, with number excluding learning disability or dementia (31) of places Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to thirty-one (31) Service Users of either sex between the ages of 18 and 65 years with a mental disorder, excluding disability or dementia, may be accommodated. Up to twelve (12) Service Users of either sex between the ages of 18 and 65 years with a learning disability may be accommodated. One person, named in the Commission`s records, who has a mental disorder and is over the age of 65 years may be accommodated. The total number of Service Users must not exceed forty-three (43). Date of last inspection Brief Description of the Service: Swanton House is a large country house situated in extensive and attractive grounds close to the small town of Melton Constable in North Norfolk. There are a number of cottages in the grounds that have their own kitchen/kitchenette facilities and offer the opportunity for more independent living by service users. The complex also has a purpose built activity centre. The accommodation in the main house is located on both ground and first floors. Fees £400 - £3000 www.swantoncare.com Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is an inspection report that looked at key standards set in the National Minimum Standards, Care Home Regulations, Care Homes for Adults. The report has been completed following a visit to the home that took place over a period of 6 hours. Information received and used as evidence from an Annual Quality Assurance Assessment (AQAA) sent by the Registered Manager prior to the visit has also been included. Comment cards from 10 residents, 6 relatives and 2 health professionals have also been received in the last month and reflected on within the report. Throughout the visit different areas of the service were looked at and evidence was obtained through observation, care plan documents, rota’s, menu’s, medication recordings, personnel files, finance records, staff training programmes and policies and procedures. A tour of the building took place and the majority of the visit was carried out with the assistance of the Registered Manager. Although overall this inspection has evidenced a number of issues it is anticipated by the new company that the planned development of the site will be the start of an improvement throughout. What the service does well: What has improved since the last inspection? Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 6 Since the last inspection the home has improved the procedures regarding medication. More stringent checks are in place with audits carried out monthly and any discrepancies investigated and staff involved spoken to. This has improved the procedures and a safer system is now in place. The home is slowly moving towards improving the care plan documentation. All care plans are now available for all staff to read. The use of agency staff has greatly reduced with the aim in the near future of having no agency staff. The kitchen store has been moved so staff no longer have to walk outside in all weathers to collect goods from the old shed store. What they could do better: The home needs to develop further the person centred care approach that looks at the person first and then their illness to be able to care for them appropriately. The introduction of care staff helping to build the care plans with the residents and nursing staff will be a move in the right direction. The residents in the house need more stimulation and activities to change the institutionalised way of life that is evident now. The policies and procedures need to be current to ensure any staff member who wishes to know how to manage a situation can find the up to date document. The home needs to find different methods that are most suitable for the individuals that will enable them to be involved in the decision making within the home. The personnel records must be checked thoroughly and ensure all documents that are required are in place before a person begins employment. Some rooms, especially in the house, need to be updated and made less institutional looking and be more personalised. Please contact the provider for advice of actions taken in response to this Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 8 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 Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home does ensure that any potential resident is suitable for the service offered at Swanton House before they are admitted. EVIDENCE: The Home is now part of the Swanton Care group and the paperwork that is offered to new residents and their families is being updated to include the most current information about the home, service users guide and statement of purpose. Information brochures about the home, that includes the service and accommodation it offers, has recently been designed by a staff member and residents in the home. (seen) The manager explained that this brochure telling people about the home will now be taken to the potential resident when an assessment is carried out. This assessment is to ensure the home can meet the person’s needs. (seen and discussed at last inspection). The majority of the people who are referred to the home come from a multi professional team based in a hospital and a lot of detail about the potential resident is already available prior to a visit from Management of the home giving clear details of the needs of the individual. The home will then assess Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 10 that information and meet the person to ensure the service offered is suitable for the individual. (Swanton House has a lot of people that have a wide range of needs and the management does look at the clientele already living in the home to ensure any new resident will be able to live in that type of community as well as having their needs met). Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The individual needs and choices is not always evident especially for residents who are unable to voice their opinion. EVIDENCE: The Home has started to transfer information on to Swanton Care paperwork. The detail written so far gives a good picture of health care needs and in the three care plans looked at the picture of personal care was limited with very little information that talked about the whole person. The Manager has started to encourage the nursing staff to use the care staff in the construction and daily recording of the care plans but this still needs some work to ensure person centred care of personal, health and social care are recorded and met. (Recommendation) On talking to some residents and by the comments written in the information sent to the Commission prior to the inspection it is not always clear how Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 12 decision making is achieved. Out of 10 comment cards returned 7 people stated they were not involved in the decision making. On talking to the Manager these residents do have the opportunity to be involved but often decline. It was not clear, due to the complex needs of some of the residents if any different communication methods of involving them had been thought through. (Requirement). The residents do have individual risk assessments (seen) but these need to be developed more as the development of care plans take place and potential risks may be identified as personal and social care needs are explored for the individual. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The lifestyles for some residents could be improved by ensuring they are involved and their rights are respected and recognised throughout their daily lives. Meals are served and offered with a choice at times of the day that suit the residents EVIDENCE: Due to the complex needs of many of the residents education or employment is not suitable but the home does try to include residents in events and community activities whenever possible. The home’s activities programme is very lively and many outings to various places such as bowling or the cinema are planned regularly. The Home also plans events throughout the year and places advertisements and posters Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 14 around the area to encourage people to be involved and come along. (The most recent being a fete where quite a few people attended from the local community). Comments from families say they are always welcomed and kept informed of any events. The home does have its own activities centre and this is used by a number of residents on a regular basis. This type of centre is ideal for residents who are more able and can use the skills kitchen etc. Noted on the day was a resident having one to one time making a rag rug. The residents in the house who, on this visit and on previous visits appear to sit in the lounge having very limited stimulation, are a cause for concern. The television was on with a very blurred picture showing a DVD. The majority of the residents could not see the screen by either being too far away or not even facing the screen. Staff are around but no constructive activity/stimulation was evident that showed any resident interaction. The chairs are all placed against the walls with only one man noted to be reading a newspaper. This lounge was seen on a number of occasions throughout the inspection visit and very little changed throughout that period of time. On talking to the Manager there are plans to have a designated staff member to concentrate on activities in the house but this is not in place yet. This was a recommendation previously and is now a (Requirement). The Home has purchased a minibus in the last year that will allow residents in wheelchairs to also go out on trips/outings and is a positive way forward to ensure all residents have the opportunity to take part as they so wish. Residents do have their rooms locked if they so wish. Staff do carry out their tasks and ensure that respect for residents property is upheld. Doors were knocked upon throughout this visit and conversations overheard were appropriate. Six comments from residents stated that their privacy was always respected with 2 others saying sometimes. (2 didn’t answer this question) The meals and menu’s are planned with the residents with some having the opportunity to shop and cook their own meal for themselves and a guest. The comment cards received stated the majority of the residents enjoyed the food with only 2 out of the 10 received saying they did not like the food. The menu’s had been sent to the Commission prior to the inspection and showed well balanced meals with choice, that are prepared at times of the day that suit the residents. Some residents require supplemented meals and these are stored correctly and in date order in the medical room. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health support offered to residents is very good but more information of the personal care needs should be documented to ensure personal requirements are met appropriately and as the individual person wishes. EVIDENCE: Limited information is available in the care plans at present on the personal care support required by each person but what is written does give brief details that enable staff to support residents in an adequate way, but this could be improved to become more person centred. (Recommendation) The Home works well with the multi professional health teams that are involved with the residents. The GP has a weekly ‘surgery’ held at the home that works well. A comment card had been received from the GP who stated that the home works well with the residents they care for. The Consultant Psychiatrist holds regular clinics at the home and the team have access to Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 16 other health professionals as and when required. The annual quality assurance assessment tells of the chiropodist that calls every six weeks. The medication is supplied by Boots in a monitored dosage system and stored in locked cabinets within locked rooms. The medication is now audited on a monthly basis and problems of medication errors have been identified and are now dealt with immediately. This has greatly reduced any administration discrepancies and records seen are much improved. Some medication administration sheets were looked at and the controlled drugs register was checked and were found to be correct with all transactions having two signatures. The home is still having some problems with this chemist and alternative methods of supplying medication is being explored that will ensure medication is available at all times when required. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Complaints are treated seriously and will be dealt with appropriately. Procedures are in place to protect residents from any form of abuse. EVIDENCE: The Commission has not received any complaints and the Manager has received three that have been managed and concluded since the last inspection. The annual quality assurance assessment completed by the manager talks about the complaints procedure and on discussion with the Manager the process of dealing with a complaint was explained. The complaints procedure is also available in paperwork given to new residents and is posted around the home for people to see. Residents also have the opportunity to voice concerns in a residents meeting. On talking to one resident he was able to say how he is happy to talk to the Manager if he is unhappy about something and 8 out of 10 comments received at the Commission stated they know who to talk to if they wanted to voice unhappiness. The home has a designated training officer who ensures staff are trained and understand about protection of vulnerable adults. The training dates were noted on the staff notice board and recently obtained certificates were seen on staff files. The home has a whistle blowing policy that is available for staff Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 18 among the policies of the home in the staff areas. All staff are checked prior to employment, by a register held centrally to ensure they are suitable to work with vulnerable residents. (These checks were seen on the personnel files for the last three staff recruited). Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home complex is being altered and extended and should benefit the residents on completion. The environment should then be more homely and less institutionalised. The home is clean. EVIDENCE: The home is undergoing lots of changes at present. On the day of the visit the new main kitchen was well underway to being completely refurbished with the home managing with temporary kitchen arrangements while the work is taking place. To improve the kitchen facilities the storeroom has been moved into the house and a small office created for the chef. This is a vast improvement as the store is no longer outside in a locked shed. The laundry is still outside at present but is about to be plumbed into the existing smoking room with that room about to be moved to what was a resident’s bedroom. This room was being painted when looking around and will be used within the next few weeks Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 20 to allow the laundry room alterations to begin. While the alterations are taking place in the main house painting of other areas have understandably been put on hold but will be carried out once the alterations have been completed. (Orders for paint have already been made). Although not much has changed in the house due to the building works, the individual rooms have still the institutionalised ‘look’. Rooms have no pictures, notices are posted on the walls of activities, toiletries are all in plastic trays and old hospital style curtains divide a shared room to provide privacy. These areas are clean and tidy but more thought needs to go into how the room should look and show how decisions are made with the resident to personalise their room to suit them as an individual. Building plans for the alterations have been seen previously by the Inspector that include the extension, development and improvement to the outside accommodation that should benefit the whole home and residents. The Project Manager for the works was able to talk to the Inspector about the plans and how the work will be carried out with as little disruption as possible to the residents. Due to this planned work the rest of the accommodation is not being improved until all the building work is completed and therefore was not inspected fully on this occasion. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff work in suitable numbers and are supported well with induction and training, ensuring that skills are in place and staff are competent. Tighter procedures on recruitment need to be in place to be sure residents are cared for by staff who are suitable to work alongside vulnerable people. EVIDENCE: The home has a designated training officer who ensures from induction to training all staff are qualified to carry out the duties expected. A planned training programme is in place ensuring that all mandatory training is offered at least three times to staff to ensure one date is suitable for the staff member. The Manager explained that if a staff member does not attend by the third date then they will be taken through a disciplinary procedure as their contract states they will be required to attend training. Many of the staff in the home are recruited from abroad and have nursing or even higher qualifications in their home country. To equate their qualifications to NVQ in this country the Manager has paid an organisation called UK Naric to Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 22 do the comparison and certificates are now on the personnel files that show NVQ 2, 3 and 4 qualifications. (seen) On talking to the staff and watching them going about their tasks it is evident that they understand and carry out their duties expertly and professionally. The home has recently advertised for new staff and had a very good response. The staffing levels have meant that agency staff were needed in the past to ensure enough staff were on duty, but current records seen show that the use of agency is reducing with the problem now only being at night. With another advertisement about to be placed it is hoped the use of agency is reduced even further. Three personnel files were looked at for three newly recruited staff. It was noted that one file only contained one reference and that had been from a friend. No one should start employment without two references being obtained. (Requirement). Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, and 42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The management of the home is carried out adequately for the benefit of the residents with improvements required on documents and policies to ensure the management is good. The health and safety of staff and residents is promoted and protected. EVIDENCE: To assist the completion of this report the Manager was sent an annual quality assurance assessment (AQAA) document to complete, prior to the inspection visit. Unfortunately the form was not completed correctly and little information could be used to help gather the evidence required. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 24 The Manager is a qualified mental health nurse and holds the Registered Managers Award. One of the responsibilities within the home is to ensure all policies and procedures are implemented. On looking at the policies and procedures held in the staff area it was noted that many of them were out of date. Some dated back to a company of many years ago and had not been correct for a long time. On talking to a staff member they knew the folder was in the staff room but were unaware that is was out of date. Some policies were new but the whole folder needed removing and policies completely removed that were no longer relevant. (Requirement). The home has a system that measures quality of different areas of the service each month. An action plan from that quality check is written and improvements are made. The home also receive monthly visits from a representative of the company who will carry out unannounced checks around the home and follow up any issues raised in the action points previously identified. These visits are recorded and copies are sent to the Inspector and are used as evidence in the writing of the inspection report. Swanton House has received regular visits and reports have been received (7 in the last eight months). Resident’s money is now held in a large safe that is locked in the office and no longer in filing cabinet drawers. (This was a requirement at the last inspection). Two accounts were looked at and the money counted. Each transaction showed the staff member’s signature and receipts and cash were counted showing that all figures were accurate. Health and safety is a promoted subject for staff and residents. Training, as mentioned previously, is ongoing with mandatory courses in fire awareness, moving and handling, food hygiene, infection control and first aid are all set to take place over the year.(seen) Staff who had already trained had certificates that were seen on personnel files and were current. Through observation staff were carrying out tasks safely. A moving and handling transfer was seen and a housekeeper was cleaning areas with the appropriate equipment, chemicals and protective clothing. The home has a maintenance officer who is working closely with the builders to ensure all precautions are taken and potential risks identified and reduced or removed during the building works. Fire extinguishers were within date of servicing. (next date due 02/08). The manager does notify the Commission of any accidents, incidents, communicable diseases and deaths. Three have been received since the last inspection and all the information had been communicated by phone informing the Inspector immediately of the issue and then the completed forms sent. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 1 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 2 X 3 x Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 26 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 YA7 Regulation 16.2m&n Requirement Timescale for action 01/11/07 2 YA14 16.2m&n 3 YA34 19.1c 4 YA40 17.3a The home must try and find ways of communicating with residents to ensure they are consulted with and make decisions about their life in their home. The home must ensure residents 01/11/07 living in the house are consulted and have available activities and facilities for recreation that suits them as individuals The home must ensure that all 01/11/07 relevant paperwork required to be held on staff who are employed is held within the home as stated in Schedule 2 of the National Minimum Standards The home must ensure the 01/11/07 policies and procedures are current, relevant and available to staff at all times. Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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 Refer to Standard YA6 Good Practice Recommendations The care plans need to reflect more aims and objectives for individuals as care plans develop and information is recorded on person, social and emotional well being. The content of the care plans need to reflect the individual personal care needs of the resident. 2 YA18 Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Swanton House Care Centre DS0000069244.V349308.R01.S.doc Version 5.2 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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