Inspection on 11/10/05 for Sweyne Court

This inspection was carried out on 11th October 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 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

Sweyne Court 03/07/07

Sweyne Court 11/07/06

Sweyne Court 01/03/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Sweyne Court Hockley Road Rayleigh Essex SS6 8EB Lead Inspector Sharon Lacey Announced 11 October 2005 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sweyne Court Address Hockley Road Rayleigh Essex SS6 8EB 01268 774530 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Excelcare Holdings Christine Anne Skeet CRH 37 Category(ies) of DE (E) Dementia over 65 - 37, OP Old Age 37 registration, with number of places Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: The service users bedrooms with an area of less than 10 sq metres will be used only following a written assessment. The assessment should include consideration on whether the facilities of the room are suitable for, and acceptable to the service user, taking into account their mobility needs. The service user plan should reflect the assessment of findings. Date of last inspection 31st January 2005 Brief Description of the Service: Sweyne Court is a two storey building set in a cul de sac. It is close to Rayleigh High Street and is convenient for buses and train transport. It is registered for 37 older people with dementia. The accomodation consists of single and double bedrooms, but some are under the National Minimum Standards and would not be suitable for wheelchair use or those needing moving and handling equipment. The home is in the process of being refurbished, with building works to change some of the bedrooms into ensuite rooms and to also increase the bedroom numbers. At present there are two lounge diners down stairs and one small lounge diner upstairs. There is a secure garden at the centre of the home which is accessible to residents and has seating available during the summer months. The home has adequate parking for visitors and staff, and there are facilities on both the ground floor for visitors to see residents in private. Sweyne Court also has a Day Centre as part of its premises, but is is run entirely seperately. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Sweyne Court changed ownership in March 2005 and is now owned by Excelcare, this is their first Inspection. This was a routine, Announced Inspection, which took place over eight hours. A tour of the home was completed and also an inspection of relevant records and documentation took place. Areas looked at included information given to residents before being admitted to Sweyne Court; information gained when residents first come into the home; how information is given to staff on the care required; the facilities and environment of the home; and any complaints that may have been received since the last inspection. Also staffing and management of the home were inspected. During the tour of the home six residents and five relatives were spoken to about their life and experiences at Sweyne Court. Many of the other residents approached were unable to express their thoughts and feelings, but it was noted that all were clean, tidy and well presented. Four staff members were spoken with during the Inspection and this feedback has been included as part of the report. Questionnaires were also sent out to relatives and their responses collated into the report. At the end of the day the Inspection was discussed with the Manager and advice and guidance was given regarding the findings. What the service does well: What has improved since the last inspection? The Home now has a Quality Assurance system in place, which approaches staff, residents and relatives for feedback on the home. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4, 5 & 6. Paperwork presently being introduced will provide sufficient information at the assessment stage. Present and prospective residents are given sufficient written information about the home to help them choose. EVIDENCE: The home’s has a Statement of Purpose and Service User Guide, which contains details of the home and also the services provided. An up to date copy of the Service Users Guide and Statement of Purpose were obtained during this Inspection and it was noted that it did not contain guidance on how residents can gain access to their personal files. The Acting Manager confirmed that she visits any new and prospective residents to complete an assessment and at this stage a copy of the Service Users Guide is provided. This had not routinely been evidence on the files inspected. The Acting Manager stated that Excelcare has a draft contract/terms and conditions of the home, and once ready it will be implemented at Sweyne Court. Two files were inspected and only one contained an old style Contract, which had not been fully completed. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 9 Due to the recent change of ownership, the home is in the process of introducing new paperwork and procedures to assess new Residents. The Acting Manager described a thorough admission process and explained that no one moves into the home without a home visit to ensure they are able to meet their needs. Anyone being admitted to the home is invited to visit with their relatives or friends, but this is not at present routinely evidenced. The two files inspected contained a mixture of paperwork, but the one that had been updated with Excelcare paperwork was very thorough and provided enough information regarding the care required. The Acting Manager stated that she felt that staff had the experience and knowledge to provide the care required for the present residents. Most staff have dementia training, but some updates are required. The home had sufficient equipment appropriate to the care it provides. It was noted during the inspection that there was a good relationship between an agency staff member and the residents in the upstairs lounge. Sweyne Court does not provide intermediate care. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7, 8, 9, 10, & 11. When fully completed the new care plans will provide sufficient information regarding the care required. It is clear that referrals are made to appropriate professionals to ensure that the resident’s health care needs are being met. EVIDENCE: Excelcare have a comprehensive care plan, which when fully completed covers all the required information. Two residents files were inspected; one contained Excelcare paperwork and this had detailed information on the assessment and also a comprehensive care plan on the care required and how it was to be provided. The second file contained a variety of forms, but the information recorded was not as clear. The Acting Manager confirmed that it is her intention to eventually transfer all the present resident’s information onto the new paperwork. Approximately one third of care plans have now been updated. There is a space to record when residents and relatives have been involved in their plan of care, and the up to date file had sections of information which had been completed by the family. The files seen did not contain clear evidence of monthly reviews. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 11 The files contained clear evidence to indicate that Residents are supported and have access to a variety of healthcare resources (optician, dentist, GP, District Nurse, Community Psychiatric Nurses etc). The home has specialist equipment to help in the prevention pressure sores. The home has policies and procedure for death and dying and they try to ensure Residents are able to stay at the home in familiar surroundings for as long as possible. It was noted that not all files contained details of the Residents wishes in relation to death and dying. The privacy and dignity of residents is covered as part of the home’s induction process. Sweyne Court has a lot of dependent residents and many require the assistance of two staff members for personal care, toileting and hoisting. Two staff were observed hoisting a resident and others assisting with toileting and the privacy and dignity of the residents was upheld. Screening is provided in double rooms to ensure privacy is not compromised. It was noted during lunchtime that the dignity of those residents who needed assistance with feeding in the main lounge/diner was not always upheld. Some residents were left with their meals in front of them and help was not provided until most others had eaten both courses. Fast modern music was also playing in the background not providing a relaxed atmosphere. Drinks were not provided until after both courses had been cleared away. The privacy and dignity of residents in lounge one was discussed on a previous visit, when it was noted that staff were standing over residents whilst assisting with feeding. Observations in the other lounge/diners was very positive, residents were assisting in setting the tables, napkins were provided, staff sat and assisted with feeding and were noted to be talking to the residents. Drinks of both juice and tea were provided during the meal and there was a pleasant atmosphere. Excelcare has a policy on the Administration of Medicines, but this was not viewed during this inspection. The storage, practices and records were inspected and these were well maintained. It was noted that some residents were on PRN medication, but no guidance or protocols were seen. The home had informed CSCI in July 2005 of a medication incident and evidence was sought on this inspection that appropriate action had been taken. The Acting Manager had arranged for an in-house training update on medication practice and this had been recorded on the staff members file. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13, 14, & 15. The home offers a flexible routine, and promotes resident’s independence and choice. Visiting arrangements are open and relaxed. Daily activities are not routinely organised. EVIDENCE: There is very little evidence that any organised daily activities are taking place with residents and this was confirmed by those residents spoken to. Relatives also expressed their concerns regarding the lack of stimulation in the home and that the home once had a lady who organised activities, but little had been done since she left. During the inspection the lounges had the television on, but there was no other organised activities or one to one sessions observed. The Acting Manager stated this is an area that needs further development, some outside entertainment had been organised, but daily activities are lacking. There was also lack of written evidence of any activities organised. Routines within the home were fairly flexible and choice is provided in meals, times to get up and go to bed, clothes they wore, bathing times, etc. Independence of the residents would mainly depend on the staffing levels available within the home. The home has recently changed over to 12 hour shifts for staff, but it was too early to establish any positive or negative effects Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 13 it may have on the residents within the home. The home has an open visiting policy, although they would prefer that visitors avoid meal times to ensure the dignity and privacy of other residents is adhered to. There is a separate visitors room available if a quieter space is required. During the inspection it was noted that many residents had visitors. Most residents were complimentary regarding the food. The Cook confirmed changes had recently been made to the supplier and he had found the quality of the food to be good. Changes often had to be made to the menus due to fresh fruit and vegetables only being delivered once a week. The cook stated that the fruit and vegetables are past their best by midweek, which meant frozen vegetables had to be used. No fresh fruit was seen on offer in any of the lounges. Hot drinks were served during the day. The kitchen was inspected and it was noted that building work had been completed on the doorways. It was also noted that the tiles and floor in this area was very dusty and the Cook confirmed that it had caused extra cleaning in the kitchen. A visit from the environmental health officer had taken place during the building work and no requirements had been made. It was noted that a tray of sausage rolls were cooling down on the oven top, but these had not been covered. Both cupboards were well stocked, but no fresh vegetables or fruit were available as the home had run out and delivery was not until the next day. Two relatives expressed their concerns regarding how late breakfast is sometimes provided at weekend and that their relatives have often had to go out before this or their medication had been provided. Another resident stated that she had not received breakfast until 10.45 am on one Sunday. Some residents and relatives also expressed their concerns regarding the timespan between supper and breakfast, as many residents did not get anything to eat for more than a 12 hour period. It was confirmed that the tea often consisted of sandwiches and the supper was a hot drink and biscuit at approximately 7.30 pm. It was confirmed that snacks and drinks are available outside meal times but many of the residents at Sweyne Court would not be able to request this. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 14 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 standard(s) The home provides good information on making complaints and how to contact the CSCI. Residents rights are protected and advocacy services available if needed. EVIDENCE: There is clear written guidance in the Home’s Service Users Guide and Statement of Purpose on how relatives and residents can make complaints. On viewing the homes complaint folder, a number of complaints had been received since the last inspection, but these had been fully recorded, investigated and a satisfactory outcome reached. The CSCI had also received one complaint regarding the changes to residents communal lounge space during the building works and that there was also no system for summoning help in the new lounge. On visiting the home to investigate the complaint, it was apparent that the complaint was upheld and requirements were made. Excelcare took appropriate action and rectified the situation. An advocacy service can be arranged for any residents who need assistance, but most present residents have family to help. The home does assist with residents ‘personal allowances’ and three were checked and found in order and well documented. The Home does have policies and procedures in place to ensure the protection of service users, but these were not fully inspected. Staff have received training on the recognition of abuse and what action should be taken, but updates are required. Guidance on verbal and physical aggression is in the staff handbook. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 15 It was established that appropriate checks are in place to ensure all new recruits are suitable to work with vulnerable people, and no staff have been referred to the Protection of Vulnerable Adults list since the last inspection. Staff files were not looked at during this inspection. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19, 20, 21, 22, 23, 24, 25, & 26. Improvements are being made to the building, which will provide better accommodation and environment for the residents. Many of the carpets need attention and the home was not ‘odour free’. EVIDENCE: The environment was not fully inspected due to the home going through a major refurbishment. Bedrooms are being made bigger and ensuite facilities made available. This is having an impact around the home and many of the residents have had to move from their ‘regular’ lounges into temporary ones whilst the building work is going on. Areas of the home are ‘out of bounds’, but it was noted that during the inspection the builders were conscious of ensuring the area worked in was safe to residents and staff. The residents in the upstairs lounge that were involved in the complaint stated the environment was better and they now had more room to move around. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 17 Decoration and carpets around the home are in need of replacement, but this is being done as the building works is completed. Due to the workman being present in the home, it was noted that many of the carpets were dusty and dirty. The home was not odour free, with some bedrooms smelling of urine. One relative had expressed concern regarding dirty pads being left in the upstairs toilet and staff not disposing of them appropriately, but these were noted to be clean and tidy on the day of the inspection. Each toilet had paper towels, liquid soap and a bin. The homes sluices were noted to be safe and the doors locked. The home has a secure garden, which is accessible to the residents and has seating available. The home also has ‘security pads’ at the front door to ensure residents do not go outside without staff being aware. Sweyne Court offers accommodation to residents with a variety of walking abilities. There were grab rails around the corridors of the home and wide doorframes for wheelchairs. The Manager confirmed that there was sufficient equipment for the present residents. There is a call bell system in every room, but this was not tested during the Inspection. It was noted that the ‘call bell’ in the temporary lounge upstairs was still out of reached as the television had been put in front of it. During a tour of the home it was noted that some residents had chosen to bring in personal belongings and many of the rooms looked ‘homely’. At present some of the bedrooms would not be suitable for wheelchair users or those needing lifting equipment due to size and health and safety. None of the present bedrooms have ensuite facilities, but the new bedrooms will have this facility. Sweyne Court has its own laundry facilities and this was well organised. Most residents stated they were happy with the service and all those residents seen during the Inspection were noted to be clean and well presented. One relative raised concerns regarding how the clothing was often washed at too higher temperatures and ruined. It was noted that new table clothes had been bought, but these were now crumpled were they had been washed too hot. The home was not ‘odour free’ during this inspection and it was noted that many of the carpets were dirty and either needed vacuuming or cleaning and this had been made worse due to the building work around the home. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, & 30. The home does not have sufficient permanent staff and agency staff are still being used to meet staffing requirements. EVIDENCE: The Acting Manager confirmed that the home still need to recruit more permanent staff, but there were four starting within the next few weeks. During the inspection there were 7 staff plus one shift leader on in the morning, and six staff and one shift leader in the afternoon. As there are now three lounge/diners in use, staff need to be distributed on both floors. New rotas have been introduced and on viewing these it was apparent that staff are now having to do at least one 12 hour shift and two six hour shift a week. The Manager is supernumery to staffing numbers. The home has one domestic staff member on long term sick and they have recently started to look at the hours and responsibilities of domestic staff at the home. As previously stated the cleanliness in some parts of the home is an issue, which had been made worse by the building work presently going on. There is a core group of staff who have been employed at Sweyne Court for a long time and are aware of the residents needs. The home is now using one agency to support vacant shifts, which is giving some continuity. Agency staff confirmed that the induction they received at Sweyne Court was sufficient to enable them to do their job and be aware of residents needs. On discussion they had also receive training appropriate to working within a care home. Two Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 19 of the agency staff spoken to during the inspection had worked at Sweyne Court before and their names were often recorded on both future and past rotas. Residents spoken to were happy with the care they received from the staff, although one relative raised concerns regarding the attitude of some agency workers and their approach to the residents. Another relative felt that staff did not always appear to be aware of when their relative needed ‘extra’ help or their health had deteriorated. A questionnaire received back stated ‘when I go there the staff are always very pleasant’. Many of the regular staff have now achieved their NVQ2 and others are working towards it. Regular training is being offered and includes fire safety, infection control, first aid and moving and handling. There was clear evidence that staff had attended relevant courses and other training had been organised for the near future, but some staff required updates. Sweyne Court has a group of staff who have worked at the home for a long while and are well trained and have a good understanding of the residents needs. Excelcare have a recruitment process, which on discussion with the Manager meets with requirements and protects residents. No staff files were inspected at this visit. Excelcare have a set Induction for new staff, which the Acting Manager stated met with the TOPSS requirements. Development needs to be done on the recording and evidencing of staff inductions. Staff receive a staff handbook with relevant guidance. Excelcare have recently appointed a Regional Trainer who is in the process of introducing new training to enable staff to complete the Foundation course and register with NVQ training. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36, and 37. The Acting Manager is very experienced and has a good understanding of the residents needs. New systems and policies are being introduced. The new organisation has clear lines of accountability and support is offered. EVIDENCE: Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 21 The home has had a temporary Manager over the last few months due to sickness. She has previous experience in assisting to manage a residential care home for older people. There are clear lines of accountability within the home. During the Inspection there was clear evidence of the Acting Manager interacting with staff, offering direction and providing appropriate advice. Relatives have expressed some concerns regarding the change of ownership and that the regular manager has not been available during these changes. The CSCI have received some complaints over the last few months in connection to the building work being completed and the affect this has had on some of the residents. It should be noted that any contact the Regulation Inspector has had with the Acting Manager has always been very professional, issues have been investigated, appropriate responses received and were possible action taken. Although the home has a supervision policy this has not been fully implemented and there was very little evidence of staff supervision. Policies and procedures used by Excelcare cover the health and safety and welfare of staff and residents. The temporary Manager is aware of her responsibilities regarding safeguarding both staff and residents. Policies and procedures were in place to ensure safe working practices. Excelcare do not routinely assist with resident’s finances, most present residents have assistance from family. Some bedrooms have lockable storage for residents to keep personal possessions and valuables. The personal allowance of three residents was checked and all were correct. Staff and resident files are kept secure and Excelcare are registered with the Data Protection Act. The Manager confirmed that residents could have access to their files, but they do not at present receive anything in writing. Excelcare do have a Quality Assurance system and questionnaires are sent to staff and service users annually to gain their views. Once these have been returned they are collated and a report written. Five accidents had occurred since the last inspection and these had been fully documented and relevant action taken. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 2 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 Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 2 3 x Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 23 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 5 Requirement The Registered person must ensure that all service users are issued with a contract or terms and conditions and these are available for inspection. When fully implemented please ensure this document is fully completed and placed on residents files. 2. 12 16 (2)(mn) The Registered person must consult with service users about their interests and provide a programme of activities and provide facilities of recreation. The routines of daily living and activities must be flexible and varied to suit all service users expectations, preferances and capacities. This is in connection to organising an activities programme within the home and ensuring this is clearly recorded to provide written evidence on future Inspection Visits. 31/03/06 Timescale for action 31/03/06 Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 24 3. 15 16(2)(i) The Registered person having regard to the size of the care home and the number and needs of the service users, provide, adequate quatities, suitable, wholesome and nutritious food which is varied and properly prepared and at such time as may be reasonably required by service users. This is in connection in ensuring fresh fruit and vegetables are avaiable at all times and also ensuring meal times are suitable as at present there is a gap of 12-14 hour between supper and tea. 31/01/06 4. 15 12(4)(a) The Registered provider shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. This is in connection at looking at the present system when staff are assisting residents with eating their meals to ensure it is done with more dignity and respect. 31/01/06 5. 4 18 18(1)(a) Staff must be provided with adequate training and updates, appropriate to the work they are undertaking. This is in connection to providing staff with updates on dementia and organising Abuse training. 31/03/06 6. 7.4 15(2)(b) The Registered person shall keep the service users plan under review and service users should be involved in this process. 31/12/05 Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 25 7. 26 16(2)(k)2 3(2)(d) The Registered person shall having regard to the size of the care home and the number and needs of the service users keep the home free from offensive odours and ensure that all parts of the care home are keep clean. This needs urgent attention, especially due to the extra dirt and dust due to the building works. 31/12/05 8. 36 18(2) The Registered person must ensure that staff at the home receive regular formal supervision to support them in the work they carry out and written evidence is available on furture inspection visits. 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 1 Good Practice Recommendations Recommend that you ensure it is clearly recorded when new residents receive a copy of the home’s Service User Guide and Statement of Purpose. Recommend you clearly record any trial visits on new Residents files. Recommend you introduce a PRN form for individuals on as and when medication, so that staff are aware when this may be required. Please ensure that resident files contain details of their wishes in relation to death and dying, as this did not appear to have been routinely recorded. 2. 3. 5 9 4. 11 Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 26 5. 30 Recommend you introduce a form which clearly records that staff have received a verbal, written and practical induction. Recommend you add guidance in your Service Users Guide with regard to residents gaining access to their files and the procedure for this. Recommend that staff are to be supervised at least 6 times a year. Recommend you also introduce a supervision matrix, so it is clear which staff have received supervision and those that require it. 6. 36 7. 37 8. 7.4 It is recommended that service users care plans are reviewed on a monthly basis to update any changes of needs etc. Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Sweyne Court I56-I06 S62901 Sweyne Court V246644 111005 Stage 4.doc Version 1.40 Page 28 - 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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