Inspection on 16/11/05 for Four Seasons

This inspection was carried out on 16th 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 but made no statutory requirements on the home.

Other inspections for this house

Four Seasons 26/07/07

Four Seasons 10/01/07

Four Seasons 13/06/06

Four Seasons 02/02/06

Four Seasons 06/01/05

Four Seasons 14/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Four Seasons 81 Halifax Road Littleborough Lancashire OL15 0HL Lead Inspector Tracey Devine Unannounced Inspection 16th November 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Four Seasons Address 81 Halifax Road Littleborough Lancashire OL15 0HL 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) 01706 376809 Mrs Wendy Collinson Mrs Wendy Collinson Care Home 16 Category(ies) of Learning disability over 65 years of age (1), Old registration, with number age, not falling within any other category (15) of places Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Within the total maximum registered 16 OP, there can be up to 1 LD(E). This temporary change in the registration category will expire when the accomodation of the named resident is terminated. Schedule of accommodation must not be varied without written consent. The service should at all times employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 6th January 2005 Date of last inspection Brief Description of the Service: Four Seasons is a large detached house, which, over the years has been extended to offer personal care and accommodation to 16 service users over the age of 65 years. Nursing care is not provided. Accommodation is 16 single rooms with 12 rooms having en-suite toilet facilities. The home is located on the main A58 Halifax – Rochdale Road, approximately half a mile from Littleborough centre where a variety of shops and other facilities are located. Transport links are good with a main bus route passing close to the home and a train station is located in Littleborough. Ramped access is provided to the rear of the building. Parking is available on the main road across from the home and a small area is also located to the rear of the property. There are garden areas to the front and rear of the home. The home is owned and managed by Mrs Wendy Collinson. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 16th November 2005 by 1 Inspector. The inspection started at 9.00am and finished at 12 noon, a period of 3 hours. 3 residents were spoken with during the inspection, along with the deputy manager, and other staff. The particular areas looked at on this inspection were: how the home is maintained, if sufficient staff are on duty and what training they have had to help them do their jobs better, what systems the manager has in place to ask residents and visitors what they think of the home, and how the manager ensures that the home is safe for residents and staff. Areas not looked at on this inspection will be covered on the next inspection. The manager of the home is also the owner of the home. What the service does well: The home is small and friendly, and this has always been a positive at Four Seasons. As the home is small, staff are able to get to know residents well. This was evident from discussions with staff, and also in seeing the positive relationships which staff and residents have with each other. There looked to be genuine fondness between staff and residents, with light hearted conversations in a friendly manner taking place. The staff team are a stable team with many having worked at the home for many years, this shows that the home is a happy place to work. The home is well maintained, and the manager has an ongoing programme of redecoration and replacement of carpets, furnishings etc. The home looks nice, furniture is in good condition and comfortable for residents, and the home is clean. Residents spoken with said they felt the home was “kept clean” and they were appreciative of the “comfortable surroundings” they found themselves in. One resident said she had looked at this home “and never wanted to look anywhere else” she further went onto say she “had not been disappointed”. One resident commented that “it couldn’t be better”. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The manager has done some of the things she was asked to do at the last inspection but not all. The things the manager has not done, she has been asked to do again. The manager needs to make sure that everything the Commission For Social Care Inspection (CSCI) asks her to do is done within the timescales she is given. If she is not able to do this, she must write to the CSCI giving her reasons for not doing as the Commission has asked her to do. She needs to make sure that all new staff complete an induction programme which meets the specification detailed by the organisation called Sector Skills Council (previously known as TOPSS). This will ensure that all staff work to a consistent standard from starting at the home. The manager needs to make sure that she (and/or her deputy) sees all staff on a planned basis to discuss their care practice, and their development including any training needs she has identified with them. This process is called supervision, and the manager must make sure that she records these meetings with each member of staff so that she and the staff member are clear as to what has been discussed. She must also demonstrate to the CSCI that she is undertaking these meetings 6 times per year with all staff. The manager must make sure that she has 2 references in place for each new member of staff before they start work at the home. Also when she is interviewing potential carers she must make sure that she asks them questions about where they have worked before and checks out with them that this information is on the application form fully. Training is in place, and documented on each staff member’s file. However there is no training overview plan in place, which demonstrates to the CSCI and the manager how many of the staff group are trained to NVQ2, food hygiene, infection control, moving and handling, fire safety, or if staff have received training for 3 days in every year. Whilst most staff have had an element of the above training, without such overview, it is time consuming for the manager to demonstrate to the CSCI what she has provided, and likewise, if she wishes to identify gaps in training she needs to go through every file to see what training individuals have had, which again is time consuming. The manager must put into place a formal system whereby she asks residents and visitors to the home what they think about the home and the care provided – this is known as a Quality Assurance system. This will allow the manager to make any necessary improvements to the home or how staff work Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 7 or if residents and visitors feel something is done really well, she can make sure she and the staff keep on doing it well. 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. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the key standards were inspected on this inspection. inspected at the next inspection. EVIDENCE: They will be Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 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 the following standard(s): None of the key standards were inspected on this inspection. inspected at the next inspection. They will be EVIDENCE: Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the key standards were inspected on this inspection. inspected at the next inspection. They will be EVIDENCE: Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the key standards were inspected on this inspection. inspected at the next inspection. They will be EVIDENCE: Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The home is well maintained providing for a homely and comfortable environment for residents. EVIDENCE: The home is well maintained, with the provider recently having redecorated the hall, landing, 1 bathroom and the exterior of the home. 2 bedrooms have been redecorated, and a number of carpets cleaned. The home has not had any recent visits from the Fire Officer or Environmental Health with the last visits having been undertaken in January 2004, and November 2003 respectively. Requirements made by both reports have been complied with. Laundry facilities are located near to the kitchen. 1 washer and 1 dryer are provided, with both being in good working order. No separate laundry assistant is employed, with staff undertaking laundry of residents clothing and bedding as part of their normal daily duties. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 14 Residents spoken with said they felt the home was “kept clean” and they were appreciative of the “comfortable surroundings” they found themselves in. One resident said she had looked at this home “and never wanted to look anywhere else” she further went onto say she “had not been disappointed”. One resident commented that “it couldn’t be better”. Staff are provided with protective clothing and this was evidenced during the inspection. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29,30 The staff have a good understanding of the residents needs. This is evident from the positive relationships, which have been formed between the staff and the residents. The arrangements for induction are insufficient, potentially leaving new staff with insufficient knowledge of their caring role and responsibilities. EVIDENCE: At the time of this visit, the home was accommodating 15 residents, having 1 vacancy. The rota evidenced 3 staff on for the morning period, reducing to 2 for the afternoon period, and then 2 waking night staff provided. The deputy manager said this was the normal staffing level worked to. In addition to the care staff, the manager of the home does spend time “on the floor” and will often assist residents with their personal care. Residents spoken with were highly complimentary about the staff group and the owner, saying they all “worked very hard”, “they are lovely with all of us”, “nothing is too much trouble” and “the girls are very patient”. Observations made of interactions with staff and residents demonstrated that staff and residents have a good relationship, which included humour, lively chat, as well as respectfulness. The files of 2 recently recruited members of staff were looked at. 1 contained all the required information with the exception of 2 references – only 1 had Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 16 been obtained, and the 2nd file contained all the required information although the employment history of the person had not been fully explored. The home has an induction programme in place, which acquaints people with Four Seasons. However, it has not yet put into place an induction programme with meets the Sector Skills Council (TOPSS) specification. This was raised with the manager at the inspection of January 2005 and it was made a requirement of that report that she introduces it for all new staff. The manager said she had just sent for some information and was waiting for it to be delivered. Training is provided for staff – sometimes through the use of in-house videos, the manager will facilitate some in-house, the home accesses the free training provided by the Council and some external training is funded by the provider. Staff have individual training files which details all the training they have undertaken. Training includes NVQ2 of which 8 staff have the qualification, and 4 staff are currently undertaking such training. On completion of NVQ2 the home will have in excess of 50 of the staff group trained to NVQ2. Other training provided includes fire safety, food hygiene, 1st aid, falls awareness, and moving and handling. However, as this training is only recorded individually rather than being recorded collectively as well, it is not possible to gain an overview of the training provided to the staff as a group. The provision of a training tool which gives an overview of the staff training will enable the provider to demonstrate that she does ensure staff receive training 3 days per year. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The systems in place for resident consultation are poor, with little evidence that residents views are sought and acted upon. The systems in place for ensuring that residents live in a safe environment are good thereby reducing the risk of injury to residents, staff or visitors. EVIDENCE: The manager of the home is nurse qualified, holds her Registered Manager’s Award, and is an experienced manager. No formal quality assurance system is in place which regularly ask residents and/or their visitors what they think of the home. Several ideas for this were discussed with the manager. The manager said she does listen to what residents say/want and acts accordingly although this is not a formal process but something she does daily on an ongoing basis. No records are kept of Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 18 such discussions or what she has changed as a result of them. Residents spoken with said they “would speak with staff if they were concerned about anything” but none particularly felt that they could influence how the home was run, although this was not a problem to them. The manager does spend time on “the floor” as previously mentioned. She is very much involved in the care of residents and often will be involved in the “handover” between differing shifts. Whilst she is involved in the daily lives of the residents and the staff, she does not undertake formal supervision although this was a requirement of the last inspection report. Insurance certificates were in place and up to date. The home has a policy which states that they do not hold any monies or valuables for residents, and any such matters/items must be dealt with by the resident or their family/representative. Records supporting the annual servicing of gas, fire and electrical appliances were in place, and a certificate confirming the 5 yearly electrical check was in place and valid. Staff have received appropriate training in moving and handling, and the home has a mobile hoist to assist staff in lifting residents safely. Risk assessments are generally in place for residents, although one file looked at did not contain an appropriate risk assessment on the use of bed rails. The manager said the bed rails were no longer required, but conceded there should have been a risk assessment in place. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 2 3 3 Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP30 Regulation 18 Requirement Timescale for action 31/12/05 2 OP36 18 3 OP29 19 4 OP33 24 An induction programme which meets the specification of the Sector Skills Council (TOPSS) must be put into place for all new staff. (The previous timescale of 28/2/05 was not met) A formal supervision programme 31/12/05 which ensures that all care staff receive supervision at a minimum of 6 times per year must be put into place. (The previous timescale of 28/2/05 was not met) At least 2 references must be in 05/12/05 place for a new employee prior to them commencing work at the home, and any gaps in employment history explored and documented at interview. A Quality Assurance system 31/01/06 must be put into place which allows the manager to check out with the residents and visitors what they think of the home. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 21 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 OP30 Good Practice Recommendations A training matrix which identifies all the staff group and their training (including dates) should be devised. Four Seasons DS0000025472.V262558.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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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