Inspection on 02/11/05 for The Swallows

This inspection was carried out on 2nd November 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Swallows 13/07/06

The Swallows 28/04/05

The Swallows 09/11/04

The Swallows 03/06/04

The Swallows 11/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Swallows, The 183-189 Hanworth Road Hampton Middlesex TW12 3ED Lead Inspector Louise Phillips Unannounced Inspection 10:00 2 & 9 November 2005 nd th Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 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 Swallows, The DS0000017369.V263214.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Swallows, The Address 183-189 Hanworth Road Hampton Middlesex TW12 3ED 020 8783 0354 020 8783 0354 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) Owl Housing Limited Ms D Brenner Mr David Roger Junior Brum Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2005 Brief Description of the Service: The Swallows is a purpose-built single storey care home. The home is set back from the main road and has a wheelchair accessible well-maintained garden to the rear of the property. The Swallows is registered to accommodate six service users with learning disabilities and is well-equipped for supporting individuals with physical disabilities or mobility problems. Each service user has their own bedroom which is specifically designed to cater for individual needs. The premises is owned by Thames Valley Housing and managed by Owl Housing. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days for approximately 5 hours with time spent talking to the manager, staff, residents and viewing paperwork. A tour of the premises took place and staff and care records were inspected. Three of the staff on duty and two of the residents were spoken to during the inspection. What the service does well: 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. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 5 Good progress has been made to the information provided about the service. EVIDENCE: The home has a well-presented Service Users Guide titled ‘Tenants Handbook’ that provides all the relevant information about the service. Each resident has a tenancy agreement detailing the terms and conditions of their living at the home. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 and 10 The needs of the residents are met, but the home must ensure that the care plans reflect the most up-to-date support needs of each resident. Improvements are needed for the staff to develop good practice in recording information about residents. EVIDENCE: On this visit two residents files were looked at and found to provide a wealth of information about each persons’ likes and dislikes, what they enjoy doing, communication needs and guidance from various healthcare professionals on managing individual physical needs. Records indicated that the care of one resident was reviewed in March this year, and future goals identified in relation to their increased contact with family and changing social behaviour. However, there was no record that these had been developed into care plans. In addition, these goals were not identified in the new care plan for the resident, dated May 2005. This is with reference to the new care plan format that has been developed for the service since the last inspection. The new format is comprehensive, enabling details of the specific needs, aims and objectives and actions to be taken by the individual resident or staff to meet these. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 9 However, the care plan dated May 2005 was not signed by the resident/ keyworker. The deputy manager stated that the care plan had not yet been implemented, despite having been developed six months ago. The previous inspection required that a more standardised format of care plan is developed for the service, and that the care plans are reviewed at least every six months. Some progress has been made to meet this, with development of the new care plan format. However, this requirement is restated due to these not having actually been implemented and not reflecting the most up-to-date goals of the resident, as drawn from the most recent review of their care. Since the last inspection the home has worked well to put in place a detailed risk assessment and risk management plan for each resident to ensure their safety when carrying out activities. Minor improvements are needed in this area, by firstly putting a copy of the most recent plan in the individual residents file to enable staff to access these easily, and reviewing the plan more frequently than the current practice of approximately every eighteen months. The record-keeping in each residents daily record book still needs to be improved further as the current practice of leaving clear gaps between each entry is bad practice and can lead to fraudulent entries being made. All the staff team should be trained and made aware of accurate record-keeping techniques. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 16 and 17 The staff have a good understanding of each residents needs and the approach of the home is flexible to cater for individual needs. EVIDENCE: During the inspection there were some residents in the home, whilst the others were out at the daycentre. The ‘shift plan’ for the day detailed the planned activities for each residents for that day, along with guidance that each resident should be asked if they want to go to the day centre/ shopping, or if they would prefer to spend time at the home. The atmosphere was very relaxed with one resident in bed until later in the morning, and another being able to get washed and dressed when they wanted to. The deputy manager stated that most residents had been on holiday this year, with the support of staff and that day trips are also arranged, particularly during the summer months to various places. Indeed, one resident discussed that they had enjoyed “…fish and chips at the seaside…”, on a recent trip they had been on to Brighton. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 11 There are pictures of the different meals that residents can choose for the weekly menu, along with the each of them being involved in the choice for the Sunday lunch and Saturday night takeaway meal. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents are well supported with personal care, receiving this when they want and with assistance if needed. Good improvements have been made to medication recording at the home. EVIDENCE: As stated earlier in the report, there is the flexibility at the home to enable residents to get up at their preferred time and attend to their personal care needs went they want. Residents seen throughout the day were all wellpresented, with clean clothes and attention paid to maintaining individual hairstyles. Where there are specific needs in this area, the resident’s files were seen to contain information from physiotherapists for staff to safely assist residents with their washing and dressing. In addition, the documentation demonstrates that the home seeks guidance from various healthcare professionals to inform staff of the correct approaches to use when eg. assisting individuals to eat, and when dealing with behavioural issues. The home must ensure that this guidance is incorporated into the care plan for each resident. Since the last inspection good improvements have been made to the recording of medication given, where the deputy manager discussed that the records are Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 13 now checked by staff at the end of each shift to ensure that all medication given has been signed for. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has an accessible complaints policy and procedure for the use of residents and visitors to the home. Adult protection is inadequate with the lack of staff training and understanding of adult protection issues potentially leaving the residents at risk of abuse or exploitation. EVIDENCE: On display in the hallway of the home is a brightly coloured notice detailing how to make a complaint, including pictures to highlight points of the written procedure. The previous inspection required that all staff receive training in the ‘Protection of Vulnerable Adults’ (POVA) to ensure that they have a thorough understanding of adult abuse issues and the action to take should they be aware of any such incidence. No staff have received this training and this requirement is restated. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 26 The décor within the home is generally of a good standard and is homely and comfortable for the residents. EVIDENCE: On entering the home you are met with a hallway that is tastefully decorated and spacious. A tour of the building showed that there is generally a good standard of décor throughout with individually decorated bedrooms and a wellfurnished comfortable lounge/ dining area. Some improvements are needed to re-paint areas on the walls where wheelchair use has scraped paint away from the walls and left black marks. One settee in the lounge was seen to need repairing, where the cover was quite noticeably torn. In addition, the carpets are worn and stained in a number of areas, where the deputy manager stated that these are due to be replaced in 2006. The kitchen has worktops that can move up and down to enable residents to prepare their own drinks and snacks when desired. There is a large garden to the rear of the home that is designed to enable easy access by wheelchair users. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 16 The accommodation within each bedroom is furnished with the necessary specialist equipment to support the individual residents in their daily activities and personal care needs. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 and 36 Steps are taken by the home to ensure the consistency of care to residents. Further work is needed to ensure that staff training is appropriately planned for and recorded. EVIDENCE: The previous inspection identified a number of areas relating to staff issues where the home had to improve. This inspection identified that there still remains a staffing shortage at the home, yet the manager stated that these will be reduced due to some new staff starting soon. The manager also stated that despite shortages the consistency of care is maintained through the use of agency staff, and that “…there are two staff in home at all times…”. The recruitment files of staff already employed at the home were seen to contain most information relating to their employment and recruitment checks. Not all of the files contained the required information, and the manager described that he is currently working with the human resources department in the organisation to get copies of recruitment information for all staff. Each staff file contained a form titled ‘training record’. Each one seen was blank, and the manager informed that these had only recently been Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 18 implemented at the home and that they will be developed to provide a summary of the training that each staff member has completed. Owl Housing issue a comprehensive list of staff training that the manager said he would also use to record and develop the individual training received by staff and help him develop the training plan for the following year. The staff files contain a copy of certificates to demonstrated training undertaken in first aid, fire awareness, moving and handling and health and safety. Since the last inspection one-to-one supervision sessions for staff have improved, with one support worker stating that supervision is monthly, with them being able to discuss “…any work issues, training and development needs…” Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38, 39 and 42 Good improvements have been made to the systems for auditing the service and seeking feedback from relevant people involved. The health and safety of the home is well maintained. EVIDENCE: The person-in-charge has recently been approved by the CSCI as the registered manager for the service. He demonstrates a good understanding of the needs of the residents and areas of improvement needed for the home. Since the last inspection progress has been made to the frequency of meetings for the residents and staff to discuss issues about the service. The previous inspection identified that a quality assurance system needs to be implemented to seek feedback from service users, their representatives and all parties involved with the service. The manager stated that questionnaires had recently been sent to relatives involved with the service and that he is currently awaiting the responses. In addition, a quarterly audit is conducted on the service, which involves looking at areas such as staff management Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 20 issues and the care received by each resident, to see where areas of development are needed for the home. The home maintains a good record of checks carried out by external contractors to demonstrate that all the fire, water and gas systems are maintained appropriately. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X X 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 2 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Swallows, The Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score X 3 3 X X 3 X DS0000017369.V263214.R01.S.doc Version 5.0 Page 22 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 YA6YA19 Regulation 15 (1) & (2)(b) Requirement Timescale for action 31/12/05 2 YA9 3 YA23 4 YA24 The Registered Persons must ensure that the current care plans are of a standardised format and are accessible. The care plan must incorporate all the healthcare needs of the resident. The care plans must be reviewed at least every six months and a record maintained of the people involved in the review. (Previous timescale not met) 13(4) The Registered Persons must ensure that the risk assessment and risk management plan for each resident is reviewed at frequent intervals, and whenever the resident’s needs change. 13(6) The Registered Persons must ensure that all staff working at the home receive training in adult protection. (Previous timescale not met) 23(2)(b)&(c) The Registered Persons must ensure that: - the walls throughout the DS0000017369.V263214.R01.S.doc 31/12/05 31/12/05 31/03/06 Swallows, The Version 5.0 Page 23 5 YA34 19(1)(b) 6 YA35 18(1)(c) home are repainted where marked - the settee in the lounge is repaired or re-covered The Registered Persons must ensure that documents specified in Schedule 2 of the Care Homes Regulations (2001) are obtained in respect of all staff. The Registered Persons must carry out an assessment of the training needs of the staff and implement an annual training plan to ensure that staff are appropriately trained for their work. (Previous timescale not met) 31/12/05 31/01/06 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 YA10 Good Practice Recommendations The Registered Persons should ensure that training in accurate record-keeping techniques is available to staff. Swallows, The DS0000017369.V263214.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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