Inspection on 04/07/05 for Swinton Lodge

This inspection was carried out on 4th July 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

Swinton Lodge 08/09/09

Swinton Lodge 10/09/08

Swinton Lodge 18/09/06

Swinton Lodge 20/12/05

Swinton Lodge 12/10/04

Swinton Lodge 08/04/04

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

CARE HOMES FOR OLDER PEOPLE SWINTON LODGE Wortley Avenue Swinton Mexborough S64 8PT Lead Inspector Mike Hamstead Unannounced 04 July 2005 07:45. 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. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Swinton Lodge Address Wortley Avenue Swinton Mexborough S64 8PT 01709 586704 01709 578172 None Absolute Care Homes (Swinton) Ltd 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) Rosaline Baxter Care Home with Nursing 63 Category(ies) of Dementia - over 65 years of age (35), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (35), Old age, not falling within any other category (28) Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. 28 Beds in the Windsor unit for Old Age (OP), Dementia - over 65 years of age (DE[E]) and Mental Disorder - over 65 years of age (MD[E]) 2. 28 Beds in the Spencer Unit for Old Age (OP) 3. 7 Beds in the Royal Unit for Dementia - over 65 years of age (DE[E]) 4. Manager to undertake the Registered Manager NVQ level 4 award by 2005 5. A condition of registration is that one named resident under the age of 65 be allowed to reside at the home. 6. One respite bed to accommodate service users with residential/nursing care, between the ages of 55 and 65. 7. One respite bed to accommodate service users with EMI residential/nursing care, between the ages of 55 and 65. Date of last inspection 12th October 2004 Brief Description of the Service: Swinton Lodge was purpose built in 1989, and is registered as a Care Home for Older People with nursing for 63 beds. It stands in its own grounds and is situated at the end of a cul-de-sac, but close to local amenities and public transport.It is a two story building in red brick, divided into three separate units. Two of the units, Windsor and Royal, cater for Older People with dementia and mental disorder, but the Royal Unit is currently not being used due to a shortage of admissions. The third unit the Spencer unit accommodates Older People with varying needs including nursing needs.All bedrooms have ensuite facilities, with 59 single bedrooms and 2 double bedrooms, although one is currently being used as a single room, and the other one is empty.Each unit has a communal lounge and dining room, with tea and snack making areas in two of these. Bathing facilities include specialist baths, showers and hoist attachments for ease of users. There is also a shaft lift.The home offers physiotherapy and a relaxation room. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the care manager and all staff on duty, and an examination of the homes records. It also included a tour of the building to observe the accommodation. Additional information of the overall situation had been gained from previous inspection visits. The inspection commenced at 07:45 and finished at 16:45, and included talking to members of staff, and residents. What the service does well: What has improved since the last inspection? The extent of the ongoing maintenance and renewal programme shows the determination to maintain the premises in good order and is a necessary investment in most group living situations. New corridor carpets have been fitted throughout the home and in two of the lounges. In addition bedroom carpets are replaced when required, and at the present time, a new carpet for the stairs and stairwell is awaiting being fitted. Other refurbishment includes the purchase of 4 hospital type beds, 3 recliner chairs, 2 new shower chairs, a new cooker and dishwasher, a new window in the Royal unit, and new fencing outside the building. A new specialised bath is on order for the Spencer unit. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 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. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 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 Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 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 The admission process is well managed, and potential residents are provided with sufficient information to enable them to decide whether they would like to live at the home/not. EVIDENCE: A new Statement of Purpose and Service User Guide have been introduced and the Service User Guide now includes the views of residents in the home. The first floor Royal Unit registered as a separate and secure unit for residents with dementia is currently not being used, due to a shortage of admissions, but the home still wish to retain the unit in case further admissions are made. All residents are issued with a contract/ statement of terms and conditions and a sample of these terms of residency have been examined on previous inspections and found to be in order and signed by the residents or their representative A copy of the most recent inspection report is also kept at the home to enable any visitors including relatives to have access to the latest views and findings Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 9 of the home and the standard of care provided for residents arising from the last CSCI inspection. A sample of residents files were examined which showed that people are being admitted following a full assessment. This includes a combination of information obtained via residents being referred through Care Management arrangements, and evidence of the homes own assessment documentation that meets this standard. Care and ancillary staff are currently undertaking NVQ training, to demonstrate the homes capacity to meet the assessed needs of service users, and also some staff have undertaken dementia care training within the home, and further training is planned. The former deputy care manager who was an RMN provided mental health training for staff before she left in March 2005, and all the care staff have had other training sessions on issues such as violence and aggression. Training packs have been obtained on epilepsy, and nutrition. and further training on equality and diversity and nutrition and health are currently planned. The care manager has completed her Registered Managers Award and staff confirmed that they were receiving statutory training All residents are invited to visit the home to assess the quality, facilities and suitability of the home before they and/or their representatives make a decision to stay on a permanent basis. Unplanned emergency admissions are avoided where possible, as this can disrupt the lives of existing residents and the care manager looks towards planning all admissions to avoid this happening. Swinton Lodge is not registered to accommodate service users on an intermediate care basis as defined by this standard. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 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 Residents are generally well looked after in terms of their health and personal care needs, but immediate attention is required for those residents who have not been seen by the GP in over 2 years, and includes the need for their medication requirements to be reviewed. Any restrictive seating used to contain any resident must initially be discussed and agreed with the resident and social worker and or relatives. EVIDENCE: The plans of care for residents in both units, are completed by a named nurse and by care staff, and are reviewed on a monthly basis, and where possible drawn up with the resident/representative as required by this standard. Once again there were good examples of care plans being up to date and reviewed, and this is an area that continues to be much improved in recent inspections. The social needs and activities undertaken by residents are now recorded and this contributes to the overall care management system for residents. There are 2 service users on the Care Programme Approach, who both receive Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 11 consultancy reviews, but staff are still not receiving copies of the notes of such meetings which are an essential component of the residents care management, and must be obtained. There was evidence to indicate that access to all primary health care facilities for residents has improved but some residents who have been in good health, have not been seen by the GP for over 2 years, contravening the need for an annual review, and also have not had their medication reviewed during this time. Because of their responsibilities to residents, the home have complained about the situation to the Family Practitioner Service, and have also spoken to North Trent Primary Care Trust who are allegedly monitoring the situation. NHS chiropody continues to be a problem, but the care manager has arranged a special deal with a private chiropodist for the benefit of residents. The home is clearly doing all they can to promote and maintain the health of service users but clearly under difficult circumstances. The Inspector sampled the MAR sheets in the Spencer Unit, and found these to be satisfactory. The home does not have any residents who self-medicate. There were examples of dignity being maintained throughout the day, and care staff addressed residents in a polite and friendly manner. Those residents needing assistance with personal hygiene were treated with respect and dignity. There is a situation however where one resident is contained on a bean bag type restrictive chair arrangement because of the danger of her constantly falling, and it is suggested that a review be called with this residents social worker and relatives to reassess the situation to ensure that there are no possible alternative arrangements, and if not that all parties are in agreement with the practice continuing. Many residents in the home display dementia related confused behaviour, and there were examples of staff treating them in a sensitive and dignified way, assisting them where required. The care manager is awaiting final guidelines concerning new procedures for terminal care and arrangements after death to be published, which will result in the homes policies and procedures having to be changed. Residents are able to spend their final days in their own rooms, surrounded by their personal belongings, unless there are strong medical reasons to prevent this. Relatives and friends of a resident who is dying are able to stay with him/her, for as long as they wish, unless the resident makes it clear that he or she does not want them to. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 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 There are opportunities for residents to pursue personal interests, and community links are promoted. Regular communal and leisure activities are available, and contact with family and friends are encouraged to ensure links are maintained. EVIDENCE: Residents have the opportunity to exercise their choice in relation to leisure and social activities and cultural interests; food, meals; routines of daily living; personal and social relationships; and religious observance as defined by this standard. The interests of residents are recorded at the assessment stage, and then developed via opportunities being made available for stimulation through leisure and recreational activities in and outside the home, to suit individual needs, preferences and capacities. Particular consideration is given to people with dementia and other cognitive impairments. A notice board inside the main entrance displays current and future activities that are planned and there are daily activities organised by an activities coordinator. There are visiting entertainers, dancers, and the “Lost Chord” a musical entertainment group is a monthly attraction. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 13 A conversation with one resident related to a visit he had made to the Mayors Parlour in Rotherham that he had enjoyed, and the fact that his photograph had been in the local press. Residents are able to receive visitors in private, and restrictions are not imposed except when requested to do so by the residents themselves. There are occasional visits from a local Church of England establishment, who provide a service for some residents, but no residents are currently visiting church of their own accord. Residents and their relatives and friends are informed of how to contact external agents (e.g. advocates), who will act in their interests, and there is an information rack inside the main entrance to the home. There are also contact names and numbers for the Alzheimer’s Society on the notice board. There are five residents who have some control of their financial affairs at the present time, and a sample of residents monies was checked and found to be accurately recorded with receipts available. There were many examples of residents bringing their own furniture and possessions with them, and access to their own personal records is available The menus, displayed a good supply of varied and wholesome food, and a cooked breakfast is always available, and hot and cold drinks are available at regular intervals. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 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) 16 17 &18 Staff have a knowledge and an understanding of Adult Protection issues that promotes the protection of residents, but staff should remain vigilant in recognising when some residents may be making legitimate complaints and recording these on their behalf. EVIDENCE: There is a complaints procedure which specifies how complaints may be made and who will deal with them with an assurance that they will be responded to within a maximum of 28 days. Written information is provided to all residents for referring a complaint to the CSCI at any stage, should the complainant wish to do so. A record is kept of all complaints made and includes details of investigation and any action taken, but there have been no complaints received since the last inspection. The care manager is to raise the subject of complaints at the next staff meeting to ensure that all staff remain vigilant and record all incidents from residents that could be considered as complaints. All residents receive ballot papers and postal votes, and staff enable them to participate in the political process if requested to do so. Two residents voted at the polling station at the recent general election, and other residents used their postal votes Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 15 There are procedures for responding to suspicion or evidence of abuse or neglect (including whistle blowing) to ensure the safety and protection of service users, including passing on concerns to the CSCI in accordance with the Public Interest Disclosure Act 1998. The policies and practices of the home ensure that physical and/or verbal aggression by residents is understood and dealt with appropriately, and that physical intervention is used only as a last resort and in accordance with DH guidance eg. de-escalation/breakaway techniques. Any member of staff identified as being unsuitable to work with vulnerable adults would be referred, in accordance with the Care Standards Act, for inclusion on the Protection of Vulnerable Adults register. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 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 The fabric and furnishings of the home are generally well maintained, providing a safe environment for residents to live in, but immediate attention must be paid to replacing the damaged bathroom hoist chair. The home is kept clean and odour free, and systems are in place to prevent the spread of infectious diseases. EVIDENCE: Some refurbishment has been carried out since the last inspection, for example new corridor carpets have been fitted throughout the home and new carpets have been fitted in the Windsor lounge, and the Spencer dining room. In addition bedroom carpets are replaced when required, and at the present time, a new carpet for the stairs and stairwell is awaiting being fitted. Other refurbishment includes the purchase of 4 hospital type beds, 3 recliner chairs, 2 new shower chairs, a new cooker and dishwasher, a new window in the Royal unit, and new fencing outside the building. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 17 There is an ongoing maintenance and renewal programme which is a necessary requirement in most group living situations, and a new specialised bath is on order for the Spencer unit. Communal space is available which includes: rooms in which a variety of social, cultural and religious activities can take place; and residents can meet visitors in private; dining room(s) to cater for all residents; and a smoke-free sitting room. Furnishings of communal rooms are domestic in character and of good quality, and suitable for the range of interests and activities preferred by residents. There are accessible toilets for residents, clearly marked, close to lounge and dining areas, and all except two bedrooms have en-suite facilities. The home has sufficient bathrooms as required by the standard. The home provides grab rails and other aids in corridors, bathrooms, toilets, communal rooms and, where necessary, in residents own accommodation. Doorways into communal areas, residents rooms, bathing and toilet facilities and other spaces to which wheelchair users have access, are of a width sufficient to allow wheelchair users adequate access. Staff pointed out that a hoist bath chair in a Windsor unit bathroom was split, and they were having to put a towel across the chair for residents safety. This must be replaced immediately to protect residents from injury. There is outdoor space for residents, accessible to those in wheelchairs or with other mobility problems, with seating and designed to meet the needs of all residents including those with physical, sensory and cognitive impairments. The heating system in the home is a combination of under -floor central heating, and gas central heating to individually controlled radiators, and pipe work and radiators are guarded or have guaranteed low temperature surfaces. There are thermostats on bedroom and communal space walls to control the heating where there is under-floor central heating. Where the residents have stated that they do not require all or some of the additional furnishing requirement requirements, this has been recorded in their plan of care. All bedrooms are naturally ventilated with windows conforming to recognised standards, now that new double glazed units have been fitted. Lighting in residents accommodation appears to meet recognised standards, is domestic in character, and includes table-level lamp lighting. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 18 and do not intrude on service users. There is a sluicing facility and, a sluicing disinfector, and washing machines have the specified programming ability to meet disinfection standards. Hand washing facilities are prominently sited in areas where infected material and/or clinical waste are being handled. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 19 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 29 & 30 Staffing level agreements are being maintained, and sufficient staff are employed to meet the residents assessed needs. The home must improve its recruitment and selection procedures, if resident protection is to be promoted. EVIDENCE: In accordance with the home’s staffing notice, the staffing complement must be an RMN in the Windsor unit and 4 care staff in the waking day, an RGN in the Spencer unit and 3 care staff during the waking day. There were only 33 residents accommodated in the whole home at this inspection. Night-time staffing requirements are for 1 RMN and 1 RGN and 4 care staff to be on duty at all times deployed throughout the three units, but there are 3 care staff at the present time because of the reduced resident numbers, and the fact that the Royal unit is currently not being used. The staffing situation found on this inspection was that there was an RGN and only 3 carers in the Windsor unit on both the morning and afternoon shifts due to staff sickness, but this appeared adequate for 17 residents. The staffing complement in Spencer unit was an RGN and 3 care staff during the waking day, for 16 residents. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 20 The majority of staff appeared motivated and committed to providing the best possible care, and a number of the longer serving staff repeated that things were now much better in the home. There are 62 of care staff who have achieved their NVQ Level 2 qualification, that demonstrates their ability to meet the assessed needs of residents. A random selection of 3 members of staff employed since the last inspection all adaptation students from abroad, revealed that despite all three of them having worked in a care setting in the UK prior to them starting work at Swinton Lodge there were no references requested from these employers in their files. There were references requested and supplied from their originating country, but references must always be requested from their most recent employment if residents are to be protected. Staff are receiving induction and foundation training to NTO specification, and all staff have an individual training and development assessment and profile. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 21 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 34 35 36 37 & 38 Residents benefit from a home run well and in their best interests where their health and safety is generally promoted. Risk assessments are carried out to maintain the welfare of residents and staff are trained in health and safety matters. EVIDENCE: The registered manager now has 3 years experience at Swinton Lodge and is a first level registered nurse and has achieved the Registered Managers Award having been awarded a personal achievement award for her work in staff training in the home. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 22 The registered manager is responsible for no more than one registered establishment, and continues to undertake periodic training to update her knowledge, skills and competence, whilst managing the home, The care manager continues to ensure that the management approach of the home is an open and inclusive one, and opportunities such as staff meetings and unit meetings exist for staff to air their views about any issue concerning the care of residents, but also terms and conditions of service. Staff spoken to appeared relaxed and motivated and keen to update their training skills in the interest of resident care. The home has got a formal quality assurance system and also an annual development and business and financial plan, and the public liability insurance is up to date. Staff supervision is now done for all staff to monitor their progress in caring for residents and the care manager confirmed that all staff are undertaking statutory training. Residents have access to their records and information about them held by the home, as well as opportunities to help maintain their personal records, but the experience is that this is very rarely requested. Individual records and home records are secure, up to date and in good order, and are constructed, maintained and used in accordance with the Data Protection Act 1998 and other statutory requirements. All the safe working practice certificates concerning, fire records, gas boiler servicing, Legionella checks, hoists and shaft lift “Thorough Examinations” and electrical wiring check were satisfactorily completed. Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 23 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 24 Yes 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 YA 8 Regulation 12 Requirement The registered person must ensure that the home obtains notes of all consultancy meetings relating to residents on the CPA programme The registered person must ensure that all residents healthcare needs are being met, with particular reference to the absence of annual health checks and medication reviews for some residents. The registered person must ensure that an immediate review is held to discuss the bean bag type restrictive chair used for a resident. The registered person must ensure that all specialised equipment is in good order to safeguard residents health and welfare. The registered person must ensure that residents are supported and protected by the homes recruitment policy and practices. Timescale for action Immediate 2. YA 8 12 30/09/05 3. YA 8 12 30/07/05 4. YA 22 23 Immediate 5. YA 29 18 Immediate Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 25 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 Good Practice Recommendations Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection 1st Floor Barclay Court Heavens Walk Doncaster, DN4 5HZ 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 Swinton Lodge J55-J07 S3090 Swinton Lodge V174727 040705 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!