Inspection on 02/02/06 for Four Seasons

This inspection was carried out on 2nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 16/11/05

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 Lindsey Withers Second Inspector - Judith Unannounced Inspection 2nd February 2006 09:05 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.V279846.R01.S.doc Version 5.1 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.V279846.R01.S.doc Version 5.1 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.V279846.R01.S.doc Version 5.1 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 accommodation of the named resident is terminated. The service should at all times employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. Schedule of accommodation must not be varied without written consent. 16th November 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.V279846.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors over a 4 hour period and was unannounced. The main focus was on those areas not assessed during the previous inspection, so that over both visits all key standards were looked at. Part of the time was spent with the Deputy Manager going through the paperwork that has to be kept to show that the home is being run properly. Part of the time was spent watching practice in the main lounges and dining areas. The Inspectors had conversations with two members of staff and six residents, though residents generally made few comments. The Inspectors were unable to follow up on some requirements made at the last inspection and to fully inspect key standards at this inspection because the owner/manager was unwilling to contribute to the inspection process. The inspection reports produced since 2004 have shown that the quality of care provision at Four Seasons is declining. The timescales set that relate to quality assurance and quality monitoring – where the home does its own measurement of “How are we doing?” - have been outstanding for a year. The general outcomes of the inspection, together with examples of the evidence found, were discussed with the Deputy Manager at the time of the inspection. What the service does well: What has improved since the last inspection? It was not possible to determine what improvements had been made because of the response from the Manager. The only improvement noted, therefore, was the redecoration of the main lounge/dining room. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 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. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home could not demonstrate that the needs and expectations of the prospective residents are known and, therefore, that they could be met by the home. EVIDENCE: The files for four residents were looked at. None contained pre-admission assessments that had been completed by the home, though information supplied by other health and social care professionals such as social workers was on file. For one person the assessment had been written in June 2005 but the person had not been admitted until October 2005. There was no evidence to show that the home had checked out this information and that it was up-to-date and correct. No information at all was available for the most recently admitted person. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, and 9. The content of care plans was not good enough for a judgement to be made as to whether appropriate care and support is being delivered. The home’s approach to the management of medication does not meet current best practice guidelines so compromising the safety of medication administration for each individual. EVIDENCE: Care plans had been written for all residents with the exception of the most recently admitted person for whom no paperwork was available. There was no evidence to show that care plans had been written based on an assessment by the home, or that care plans are reviewed and updated on a regular basis. One care plan had not been reviewed since August 2005, and another since November 2005. One file had not been updated in two areas – the first since December 2004, and the second since January 2005. Except for one file, there was no evidence to confirm that residents or their supporters are involved in developing the care plan. Several files did not have the basic risk assessments for falls, nutrition, etc. Those that were in place had not been reviewed, for example, one last dated Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 10 November 2001. One falls risk assessment had been done by the hospital in May 2003 but had not been reviewed by the home. On one file a risk assessment had not been done for the safe use of bedrails (in line with best practice guidelines issued by the Medical Devices Agency), or confirmation that the resident or her family had agreed to their use. The care plan for one person referred to her needing to be “distracted by doing a bit of washing up” rather than the resident expressing a wish to do this task. The person was seen in the main kitchen washing up with a carer at a very busy time of the day and when hot food and drinks were being prepared. No risk assessment has been drawn up that relates to this activity being conducted in the main kitchen. Staff did not appear to understand that there might be a risk or that the task – or something similar - might be better carried out in an alternative place. An entry made in one record from a member of staff asked for a resident to be given “a larger pad”. Nothing could be seen in the care plan relating to continence management because there was no care plan for this person. The deputy manager said the continence nurse had not visited to see the resident. One record contained a turn chart which showed the positional changes made by staff in order for the person to receive pressure relief. However, this person’s food in and out chart, which accompanied the turn chart, was not completed in a meaningful way, i.e. “½ bowl liquidised” but no record of what food was liquidised. Weight records had not been maintained except for one person, whose last recorded weight check was in November 2005. The deputy manager said these were kept separately, but on checking, she later confirmed that they had not been recorded. Examples of information missing from care plans included activities, social profiles and property lists. Some files did not have a photograph of the resident. The way that daily progress records were completed was not satisfactory. Entries for the most part were brief: “slept well”, “ate well”, “no complaints”. One member of staff wrote entries that were demeaning to the resident and were wholly inappropriate. The deputy manager said they were aware of this person’s attitude and had spoken to her about it. Entries for one person recorded that the person had not been bathed or changed because the room was “cold”, “too cold” or “very cold”. The deputy manager could not say what had happened to the heating or what had been related at handover. She was able to demonstrate, however, that the person had been bathed and changed at other times of the day. The deputy manager Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 11 felt this was more likely to be a staff attitude issue rather than a problem with the heating. The medication for three residents was checked using the medication administration record as a guide. The medication and the associated record for the first person was correct. There was no liquid paracetamol in the medicines trolley for the second person yet some had been administered that morning. The deputy manager said they had “just run out” and that she needed to order some more. She said they had not given the person liquid paracetamol belonging to someone else. Robust procedures must be put in place, including auditing of the ordering system and management of medication, so that medication does not run out. The controlled medication for a third person was inaccurately recorded so that the person had not received her medication as prescribed. Furthermore, the controlled drug book had not been completed since 12th January 2006. The deputy manager said that staff had not received specific instruction on the administration of a controlled drug; they had not come across it in the home before. An immediate requirement was served relating to the administration and recording of controlled drugs. All medication must normally be administered as prescribed. All drugs, including controlled drugs, must be handled in line with a written procedure which staff are familiar with. None of the medication administration records contained a photograph of the resident but it would be good practice to do so. The home does not have a policy and procedure for the administration and recording of homely remedies. If the home is using homely remedies, a policy must be put in place and staff made familiar with it. A discussion took place about the best way to provide homely remedies such as paracetamol, simple linctus, etc. while ensuring these do not impair the effect of a person’s prescribed medication. The deputy manager was advised to seek professional advice from a pharmacist, GP, NHS Direct or other health professional so they could make an informed decision. Best practice guidelines set out in the Royal Pharmaceutical Society’s “The Administration and Control of Medicines in Care Homes” June 2003 states that medicines should be stored in an area where the temperature does not exceed 25 degrees centigrade. The medication trolley is currently secured in the kitchen. According to the document quoted above, examples of places classed as not suitable for storing medicines include kitchen, bathroom, toilet and sluice or next to heaters. A suitable alternative location will, therefore, need to be found for storing medicines. The deputy manager said that some medication, such as antibiotic, is sometimes stored in the fridge in the kitchen. This is acceptable provided the medicine is kept separate, is clearly marked, and the temperature of the fridge is checked and recorded. If people other Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 12 than staff have access to the fridge, then such medication should be kept in a locked box inside the fridge. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Information recorded about residents is not sufficient to allow the home to provide activities and occupation that is relevant to each individual person. Activities offered in the home is limited and, therefore, limits the lifestyle experienced by the residents. There are regular visitors to the home and residents are encouraged to maintain contact with their families and friends. Within the limits of the service provided by the home, residents are able to exercise choice and control. The records could not confirm that the provision of food to residents is satisfactory. EVIDENCE: The home did not have a programme to demonstrate that activities were provided that were suitable for the people living there. The activity file had not been completed since November 2005. The care plans did not contain sufficient social history or information on the person’s expressed interests and preferences, or confirm that a discussion had taken place to determine which were essential to a person’s happiness and which were preferable. There was, therefore, no way to measure that residents were offered the opportunity to Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 14 exercise their choice in relation to leisure and social activities and cultural interests. One resident said that the home “seemed to be OK”, but added, “I just do as I’m told.” Residents appeared comfortable with the home’s pets though the dog’s very loud bark may be a problem to someone with a nervous disposition. From the visitors’ book it is evident that there are regular visitors to the home though the inspectors saw none during the course of this inspection. The routines of daily living appear to revolve around meals, which are served at set times. However, some residents were seen to be served breakfast in their own rooms, though it was not clear whether this was the normal habit of the resident or because the dining room was being redecorated and was not in use. The Inspectors observed the breakfast and lunch-time servings. The food presented to residents looked appetising and two residents said the food was good. However, several areas for improvement were identified. The menus (meal choices) do not reflect best practice guidelines, such as The Caroline Walker Trust “Eating Well for Older People” – a copy of which the home has for reference - or as recorded in the home’s policy relating to meals and nutrition. It is not acceptable to serve lemon curd sandwiches or teacakes for the evening meal unless the resident expressly requests them. This type of food should be served as afternoon tea, not as a meal. Menus are not printed in a suitable format for residents to read and understand. The day’s menu did not reflect what was served: neither of the two alternatives served during lunch were on the menu. On some days, the menus do not offer alternative choices. There was insufficient evidence, therefore, to determine that a nutritious diet is provided or that residents have been consulted with about what is served. Health and safety issues relating to the kitchen are discussed at Standard 38. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 15 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): 16 and 18 The home has a complaints policy that is available to residents and their supporters. The home does not have a policy that relates to the protection of vulnerable people, and staff said they had not received training in this topic or in abuse. Residents cannot be assured, therefore, that they will be protected from harm or exploitation. EVIDENCE: The home’s complaints procedure had been written in July 2003 and does not appear to have been reviewed or revised since that time. The home had no recorded complaints. None had been received at the CSCI since the last inspection. The policy and procedure manual did not contain anything that related to the Protection of Vulnerable Adults. Staff said they had not received any training about the protection of vulnerable adults or abuse. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 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 the following standard(s): 19, 25, and 26 Four Seasons is clean and generally well-maintained throughout. The comfort and safety of residents is compromised when temperatures of heating and water are not regularly checked and monitored. Staff working between laundry, kitchen, and care can pose a risk to the control of infection in the home. The standard of hygiene in the home, therefore, needs to be reviewed. EVIDENCE: The home was clean and fresh throughout, and there was evidence of redecoration in the main lounge/dining-room. Arrangements were being made for the carpet to be deep cleaned before the room became open again to residents. Staff said new curtains had been ordered. The hot water in the bathroom facing room 13 was running at 60ºC which is far beyond the safe temperature of 43ºC. This safe temperature is stated in the home’s policy. Staff had made recorded three entries relating to one person which stated that the room had been “cold”, “very cold”, and “too cold”. Water storage and room temperatures need to be checked so they are at safe and comfortable levels, and records kept. The home’s policy states that bathrooms Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 17 must be clean and tidy at all times. However, bathrooms were found to be untidy and cluttered, some being used as storage rooms. This action reduces the choice of bathing facilities available to residents. The laundry is located near to the kitchen. As part of their normal daily duties, staff work in the laundry and kitchen as well as providing personal care to residents. Staff were not seen to be wearing protective clothing, such as aprons and gloves, that was appropriate to each area of work. There is the potential, therefore, for the control of infection to be compromised. Other health and safety issues are discussed at Standard 38. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 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 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): EVIDENCE: This section was not assessed on this occasion. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 19 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, and 38 The number of requirements and recommendations made during this inspection gives some cause for concern as to the quality of management being provided in this home. The home does not have sufficient systems in place to review and reassess the standard of provision delivered by the home. Residents cannot be assured, therefore, that it is run in their best interests. The number of requirements and recommendations relating to health and safety issues compromises the quality of care being provided to residents. EVIDENCE: At this inspection, the Manager would not speak to the Inspectors and asked them to leave. The inspection was left in the hands of the Deputy Manager. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 20 Staff said that two recent complaints about the home had shaken the Manager’s confidence. The systems for monitoring the quality of the service provided at Four Seasons had still not been improved. No resident satisfaction survey appears to have been done since January 2004. This matter has been the subject of requirements in the last two inspection reports and remains outstanding. The policies and procedures adopted by the home have not been reviewed or updated to reflect changing legislation or good practice advice from specialist or professional organisations. There was evidence at this inspection to confirm that practice in the home does not reflect those policies and procedure that are filed in the home’s manual. Staff said that the shower in the shower room was not used, and one of the Inspectors noted that this room was being used for storage. There was no evidence to confirm that the shower head is flushed out periodically. This would be good practice in order to discourage conditions that favour the growth of legionella. The accident book made available for examination was dated 12.3.05 – 13.1.06. The book was full. The Deputy Manager could not find the new accident book, saying that the Manager “must have it”. A number of accidents were recorded that said the person had been “found” i.e. the accidents were unwitnessed. One accident had not been recorded on the appropriate documentation, but a note had been made by the Manager describing it as the person’s “own fault”. Accidents had not been audited. The home could not demonstrate, therefore, that care practice had been changed as a result of accidents occurring in the home. Doors throughout the home were wedged open using a variety of items, including folded face cloths. Such items are not the recommended safe way to wedge open doors and can compromise fire safety in the home. If doors are to be wedged open (the reason for which is recorded), only doorguards recommended by the fire service should be used. The home’s pets were allowed entry to the kitchen and were fed there. Pet food was left in trays on the kitchen floor. This is against the “Food Safety First Principles” guidance set down by the Chartered Institute of Environmental Health which states that pets can contaminate food if they are allowed into food areas. The home had a copy of this guidance in its reference library in the main office. The kitchen was often congested with a number of staff. Staff move from laundry, to personal care, to the kitchen without having washed and dried their hands or wearing clean protective clothing, appropriate to the area of work. One person continued with the preparation of drinks having blown her nose but not having washed her hands. Cutlery and crockery washed by hand in the kitchen sink was not rinsed after washing. One Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 21 resident was able to wander into the kitchen at will, even at a time when hot food and drinks were being prepared and served. This level of activity in the kitchen appeared to be the normal way of working but the flow of work and the methods used need to be reviewed in order to minimise risks. A box of toiletries and a tub of sudocrem (all un-named) were found in the bathroom facing room 13. Items such as these should be returned to residents’ rooms as soon as they are finished with and kept out of reach of vulnerable residents, some of whom might mistake shampoo, bath foam, etc. for a drink. Communal toiletries should not be used as they could pose a risk to the control of infection, and do not offer individual choice to residents. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X 2 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X X X X 1 Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 23 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 OP3 Regulation 14 Requirement All residents must be thoroughly assessed by the home prior to admission being arranged. Assessments must take account of the views of health and social care professionals, as well as those of the person and their family. Each person must have a plan of care. These records must be kept in the home so they are available to staff. Care plans must be kept under review. The expectation is that this will be at least monthly. Risk assessments must be put in place, relevant to each person, and must be kept under review. The expectation is that this will be at least monthly. The record of nutritional intake must state clearly what liquidised diet has been taken. A record of weight, including gain or loss, must be kept for each person. The ordering and management of medication must be audited regularly. Procedures must DS0000025472.V279846.R01.S.doc Timescale for action 10/03/06 2 OP7 15 10/03/06 3 4 OP7 OP8 15 13 10/03/06 10/03/06 5 6 7 OP8 OP8 OP9 17 17 13 10/03/06 10/03/06 10/03/06 Four Seasons Version 5.1 Page 24 8 OP9 13 9 10 11 OP9 OP9 OP9 13 13 13 12 OP12 16 13 OP15 16 14 OP18 12 15 OP25 13 16 OP25 23 17 OP25 23 make sure medication does not ‘run out’. Policies and procedures describing the safe handling of controlled drugs must be implemented. Immediate requirement made 02/02/06 Medication must normally be given as prescribed. Immediate requirement made 02/02/06 A more appropriate location must be found in which to store the medication trolley. Where used, homely remedies must only be administered in accordance with procedures describing their safe handling. A programme of activities must be devised that takes into account the views of residents, and which promotes well-being. Menus must be reviews that food is offered that is nutritious and wholesome, and based on good practice guidelines. It is the expectation that residents’ views will be taken into account when devising the new menus. The home must implement a policy and procedure relating to the protection of vulnerable adults. Staff must receive training. Water temperatures must be checked regularly and adjusted as needed, so that water is delivered at a safe temperature. Room temperatures must be maintained at levels that are satisfactory to the residents. Lack of heat must be investigated and corrective action taken. Suitable storage must be made available so that bathing facilities for residents are not reduced or compromised. DS0000025472.V279846.R01.S.doc 02/02/06 02/02/06 31/03/06 10/03/06 31/03/06 31/03/06 31/03/06 10/03/06 10/03/06 31/03/06 Four Seasons Version 5.1 Page 25 18 19 OP26 OP31 13 10 20 OP33 24 21 OP33 18 22 23 OP38 OP38 17 17 24 OP38 23 25 26 OP38 OP38 38 38 The system for controlling infection within the home must be improved. The Registered Manager must be able to demonstrate that she manages the home with skill, competence and care. A quality assurance and quality monitoring system must be introduced. Timescales 31/1/06 and 28/2/05 not met. The home’s policies and procedures manual must be reviewed and updated. Practice in the home must reflect its policies and procedures. All accidents and incidents must be recorded. Accidents must be audited regularly to identify changes to care practice needs to the implemented. Only suitable equipment, as approved by the fire service, must be used if doors are to be wedged open. The flow of work and people in the kitchen must be reviewed in order to minimise risks. Toiletries must be removed from communal bathrooms and returned to residents’ bedrooms after use. 10/03/06 10/03/06 31/03/06 31/03/06 10/03/06 10/03/06 10/03/06 10/03/06 10/03/06 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 OP7 Good Practice Recommendations Recording in documents relating to residents should be informative and meaningful. Entries should not demean or DS0000025472.V279846.R01.S.doc Version 5.1 Page 26 Four Seasons 2 3 4 5 6 7 8 9 10 11 12 OP7 OP9 OP9 OP9 OP15 OP15 OP38 OP38 OP38 OP38 OP38 disrespect the resident. It is good practice to include an up to date photograph on each resident’s file. It is good practice to include an up to date photograph on each resident’s medication record. If medication is kept in the kitchen fridge, it should be kept separate and be clearly marked. The temperature of the fridge should be checked regularly. If people other than staff have access to the fridge, medication should be kept in a locked box inside the fridge. Menus should be available that are printed in a form that is suitable to the residents. Each day’s menu should offer alternative choices. It is good practice to flush out unused shower heads periodically. Pets should not be allowed in the kitchen. If care assistants have to prepare food, their protective clothing should be sufficient to avoid risks of contamination. Food handlers should be dedicated to that task and not move between catering and caring. Each person working in the kitchen is expected to maintain a high level of personal cleanliness. Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Four Seasons DS0000025472.V279846.R01.S.doc Version 5.1 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. 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. 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