CARE HOMES FOR OLDER PEOPLE
Swarthmore Marsham Lane Gerrards Cross Bucks SL9 8HB Lead Inspector
Nichola Cahill Unannounced Inspection 13th February 2006 09:30 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 DS0000023069.V284850.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. DS0000023069.V284850.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Swarthmore Address Marsham Lane Gerrards Cross Bucks SL9 8HB 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) 01753 885663 01753 891645 carehome@swarthmore.co.uk Swarthmore Housing Society Limited Mrs Janice Windle Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places DS0000023069.V284850.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th September 2005 Brief Description of the Service: Swarthmore Residential Care Home is situated in Gerrards Cross, Buckinghamshire. The home was opened in 1947 and was founded by members of the Religious Society of Friends (Quakers). The home was originally opened for the accommodation of members of the Society of Friends, however the home happily accepts non-Quakers. Swarthmore is registered for 40 older persons, not falling into any other category. The home is situated close to all local amenities, which include, shops, pubs, library and cinema. Service users are able to access such amenities on foot, by car or use of the local bus service. The home has a local GP practice with the support of a district nurse team if needed. Service users are actively encouraged to use the services of a GP of their choice. Other healthcare services are also available by way of a referral through the GP, such services include, physiotherapists, occupational therapists and podiatry. DS0000023069.V284850.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the summary of the annual unannounced inspection carried out by Nicky Cahill (lead inspector) and Gill Gentles (inspector) on 13th February 2006. The inspection commenced at 11.10am and was carried out over two and half hours. The inspection consisted of an assessment of core standards not inspection at the inspection visited in September 2005 and compliance against requirements made. What the service does well:
A comprehensive statement of purpose is available to ensure that service users and their representatives are fully informed regarding the services offered by the home. Medication practices in place protect the safety of service users. The home has a comprehensive policy and procedure regarding the protection of adults from abuse. Most staff have received training in this area. This will ensure the protection of service users. A complaints procedure is in place. Service users are encouraged to air their concerns and complaints and know that they will be dealt with in an appropriate manner. The numbers of staff on duty are adequate, all staff are suitably trained and will ensure that the needs of the service users are met. The homes procedures in place for the handling of service users finances protect service users from any financial abuse. The systems in place for health and safety protect service users, staff and any visitors to the home from any hazards. DS0000023069.V284850.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. DS0000023069.V284850.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 DS0000023069.V284850.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): 1 A comprehensive statement of purpose is available to ensure that service users and their representatives are fully informed regarding the services offered by the home. EVIDENCE: A comprehensive statement of purpose is available to ensure that service users and their representatives are fully informed regarding the services offered by the home. This document was reviewed in June 2005. DS0000023069.V284850.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): 9 Medication practices in place protect the safety of service users. EVIDENCE: The systems in place for the safe handling and administration of medication were partly assessed. Medication is stored in a lockable facility in the homes main office. The keys to access medication are held by the senior on duty. The home has a controlled drugs cabinet, which is double locked. One concern was noted during the previous inspection visit with regard to the recording systems in place. Recording systems have been reviewed and were found to be satisfactory. During the previous inspection it was noted that some homely remedies were being stored which were not listed on the homes policy. Some homely remedies were out of date. The home are now only storing homely remedies as per their own policy and all out of date stock had been returned to the chemist.
DS0000023069.V284850.R01.S.doc Version 5.1 Page 10 DS0000023069.V284850.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): All core standards were assessed at the inspection visit in September 2005 and were being met at this time. EVIDENCE: DS0000023069.V284850.R01.S.doc Version 5.1 Page 12 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, 18 The home has a comprehensive policy and procedure regarding the protection of adults from abuse. Most staff have received training in this area. This will ensure the protection of service users. A complaints procedure is in place. Service users are encouraged to air their concerns and complaints and know that they will be dealt with in an appropriate manner. EVIDENCE: The home has a comprehensive policy and procedure regarding the protection of adults from abuse. According to the staff training files most staff have received training in this area. The home has an in house trainer and a training pack has been produced. This is comprehensive and covers all areas expected. A complaints procedure is in place. Service users are encouraged to air their concerns and complaints and are empowered by the homes philosophies to air any concerns and complaints through their own meetings. The home has not received any complaints since the last inspection visit. Many letters complimenting the care have been received. DS0000023069.V284850.R01.S.doc Version 5.1 Page 13 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): Core standards were assessed during the inspection visit in September 2005 and were being met at this time. EVIDENCE: DS0000023069.V284850.R01.S.doc Version 5.1 Page 14 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, 30 The numbers of staff on duty are adequate; all staff are suitably trained and will ensure that the needs of the service users are met. EVIDENCE: The staffing rotas were viewed for four weeks worked prior to the inspection visit. It would appear that staffing levels are adequate and that the needs of the service users may be appropriately met. All staff now have an up to date training file. A main file was available which contained a training matrix and all material relating to training delivered. Of the twenty-nine staff the following training had been received; • 19 have received manual handling training. • 13 have received POVA training • 12 have received food hygiene • 16 have received fire awareness. Other areas of training delivered included, risk assessing, health and safety and first aid. DS0000023069.V284850.R01.S.doc Version 5.1 Page 15 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): 35, 38 The homes procedures in place for the handling of service users finances protect service users from any financial abuse. The systems in place for health and safety protect service users, staff and any visitors to the home from any hazards. EVIDENCE: The home only assists a small number of service users with their personal allowances. This will include payment of small purchases, hairdressing and chiropody. Records viewed for transactions made on behalf of service users were in order. The following health and safety records were viewed and in order: • Fire alarm servicing • Emergency lighting checks
DS0000023069.V284850.R01.S.doc Version 5.1 Page 16 • • • • Boiler servicing PAT testing Generic Risk assessments Weekly fire tests DS0000023069.V284850.R01.S.doc Version 5.1 Page 17 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X x STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 DS0000023069.V284850.R01.S.doc Version 5.1 Page 18 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000023069.V284850.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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