Inspection on 27/09/05 for Swarthmore

This inspection was carried out on 27th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Swarthmore 05/05/09

Swarthmore 17/05/07

Swarthmore 13/02/06

Swarthmore 02/03/05

Swarthmore 08/09/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Swarthmore Marsham Lane Gerrards Cross Bucks SL9 8HB Lead Inspector Nichola Cahill Unannounced Inspection 08.00 27 September 2005 th 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 Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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 Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd March 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. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the annual unannounced inspection visit carried out by Nicky Cahill on 27th September 2005. The inspection commenced at 08.00 and was carried out over a four and half hour period. The inspection visit consisted of time spent with service users over morning coffee, discussions with the manager and other staff, viewing documentation with regard to the health and well being of service users and the recruitment of staff. Medication systems were viewed and a tour of the communal areas of the home was carried out. Requirements from the inspection visit in March 2005 were assessed. Such requirements are now being met. What the service does well: New service users are admitted to the home following a pre-admission assessment, this enables the home to ensure that the assessed needs of service users are appropriately met. Service users have a detailed plan of care, which outlines their health and social care needs and the support received from other health care professionals. The routines of daily living are flexible and varied; service users are able to receive visitors to the home at any time and are supported in retaining links with the local community. Service users are supported in exercising control over their lives. The location and layout of the home is suited to the needs of the service users for which the home is registered. The home is clean, hygienic and free from any offensive odours. Service users are able to live in a safe, well maintained, environment. The registered manager is competent and experienced to run the home and ensures that the management approach creates and open and inclusive atmosphere. The home is run in the best interests of the service users. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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 Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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, 4 New service users are admitted to the home following a pre-admission assessment, this enables the home to ensure that the assessed needs of service users are appropriately met. EVIDENCE: Four pre-admission assessments were viewed during the inspection visit. Assessments covered all areas of service users health and well being. The homes manager had carried out assessments. The manager is very aware of the skills needed by the staff team to deal with the specific needs of service users. From discussions with service users and viewing documentation it is evident that the home are meeting the needs of the current service users group. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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 have a detailed plan of care, which outlines their health and social care needs and the support received from other health care professionals. Information recorded would enable care staff to meet the assessed needs of individual service users. Safe systems are in place for the safe handling and administration of medications. Some practices need to be reviewed in order to protect the safety of service users. EVIDENCE: Four care plans were viewed during the inspection. Care plans are recorded on a ‘Standex’ System for ease of use and are stored in a lockable facility. It was noted during the inspection visit in March 2005 that the care plan system was not locked and the office door propped open making care plans accessible to anyone visiting the office. The manager is, once again reminded that all confidential documentation must be locked at all times. Care plans were detailed and had been reviewed regularly by a senior member of staff. Care plans reflected the current and ongoing needs of service users. It Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 10 was evident that service users were fully supported in accessing services from other health care professionals. The systems in place for the safe handling and administration of medication were 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. MAR sheets viewed had been completed appropriately. Medication is signed into the home and any medications being returned to the pharmacist are listed appropriately. The home has a controlled drugs cabinet, which is double locked. One concern was noted with regard to the recording systems in place. The service users ‘preferred’ name was recorded in the record book, which did not correspond with the pharmacy label. One entry had been made that the balance of tablets was twenty-seven, however, a further twenty-eight tablets had been received but had not been added to the total. The record book does not clarify whether the amounts column is for amount in the home or amount administered. 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. Pepper mint water was opened on 29.01.03 and distilled witch hazel was out of date in September 2004. It is a requirement that the recording systems for controlled medications be reviewed to ensure that names correspond with the pharmacist instructions, the balance of tablets is correct and that the record clearly identifies what is meant by ‘amount’. Homely remedies must only be stored in accordance with the homes policies and guidance from General practitioners. Service users spoken to during the inspection confirmed that their privacy and dignity is respected at all times. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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 The routines of daily living are flexible and varied; service users are able to receive visitors to the home at any time and are supported in retaining links with the local community. Service users are supported inn exercising control over their lives. EVIDENCE: From discussions with service users it was confirmed that there is a full and interesting activity programme in place, which caters for the needs of individual service users. Service users may participate in art and literature classes, music recitals and other structured activities. Service users are able to get up and go to bed at a time of their own choosing. Visits to the home by relatives and friends are fully supported at any time. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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): This group of standards was not assessed at this inspection. EVIDENCE: Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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): 19, 26 The location and layout of the home is suited to the needs of the service users for which the home is registered. The home is clean, hygienic and free from any offensive odours. Service users are able to live in a safe, well maintained, safe environment. EVIDENCE: At the time of the inspection visit the home was having a new carpet in the hallway. This would complement the lovely décor around this area of the home. Some other areas of the home had also recently been decorated. During this inspection visit only communal areas were viewed. All areas were comfortable, well decorated and homely. The home was clean, tidy and free from offensive odours. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 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): 29, 30 Staff are not all appropriately trained in mandatory and specialist areas as required. This does not ensure the health and well being of service users at all times. EVIDENCE: Four recruitment files were viewed during the inspection visit. Documentation required under The Care Homes Regulations 2001 was in place in all files viewed. CRB disclosures and POVA checks had been carried out appropriately prior to the commencement of employment. Training files for five members of staff were viewed. Of the five files viewed two members of staff had not received any update training in the last twelve month period. Evidence of mandatory training was sadly lacking for all staff. It was confirmed that training files had not been reviewed for some time, however, one member of staff has now been allocated to this task. It is a requirement that all staff receive update training in all mandatory areas and that this be recorded appropriately within personal development files. The manager must forward a plan of training and confirmation that this is completed for all staff within the given timescale. Staff induction, training and supervision will be one focus of the next inspection visit. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 15 Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 16 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, 32, 33. The registered manager is competent and experienced to run the home and ensures that the management approach creates and open and inclusive atmosphere. The home is run in the best interests of the service users. EVIDENCE: The registered manager, Janice Windle, has worked at the home for ten years and has many years experience in the care field. She is presently in the process of completing her registered managers award. Janice is well supported by the homes deputy manager, administrator and an experienced and dedicated care team. It was evident throughout the inspection that the manager encourages an open and inclusive atmosphere throughout the home. Service users spoken to confirmed that all staff are approachable and will address any concerns immediately. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 17 Service users are encouraged to be involved in the day-to-day decisions regarding the running of the home and have their own committee meetings regularly. The home receives regular quality audit visits as required under The Care Homes Regulations 2001, Regulation 26. Reports from these visits are forwarded to The Commission. Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 18 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 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 X 17 X 18 x 3 x X X X X X 3 STAFFING Standard No Score 27 X 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X X Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? yes 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 9 Regulation 13 Requirement It is a requirement that the recording systems for controlled medications be reviewed to ensure that names correspond with the pharmacist instructions, the balance of tablets is correct and that the record clearly identifies what is meant by ‘amount’. Homely remedies must only be stored in accordance with the homes policies and guidance from General practitioners. It is a requirement that all staff receive update training in all mandatory areas and that this be recorded appropriately within personal development files. The manager must forward a plan of training and confirmation that this is completed for all staff within the given timescale. Timescale for action 31/10/05 2 30 18 27/12/05 Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 20 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 Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 21 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 © 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 Swarthmore DS0000023069.V253897.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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