Inspection on 25/04/05 for Four Seasons

This inspection was carried out on 25th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 02/01/07

Four Seasons 28/11/05

Four Seasons 03/11/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Four Seasons Back Lane Mickleton Nr Chipping Campden Gloucestershire, GL55 6SJ Lead Inspector Sharon Hayward Wright Unannounced 25 April 2005 10:15 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. Four Seasons Version 1.10 Page 3 SERVICE INFORMATION Name of service Four Seasons Address Back Lane, Mickleton, Nr Chipping Campden, Gloucestershire, GL55 6SJ 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) 01386 438300 01386 430071 Four Seasons Mickleton Limited Mrs Christine Davey Care Home 21 Category(ies) of Old Age (21) registration, with number of places Four Seasons Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 3/11/04 Brief Description of the Service: Four Seasons is a detached house situated in the centre of Mickleton. The property has been extended on two occasions and provides accommodation on two floors with the upper floor accessed by stairs and a shaft lift. There are seventeen single bedrooms, eight of which have en-suite facilities and both double bedrooms have en-suite facilities. Both double rooms are currently occupied by one service user but couples can use these rooms.The ground floor communal areas provide a separate lounge and dining room. Two of the six bathrooms are equipped with hoists.The Home has well tended gardens to the front and rear of the Home and a number of parking spaces at the front. Four Seasons Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. Seven service users were spoken with, to gain their views on the home and the care they receive. Four staff members, the Deputy Manager and Registered Provider were also spoken with. Staff were observed going about their duties and interacting with each other and service users. A tour of the premises took place. Servicing of equipment, care and food records were inspected as was the medication procedure used by the home. One requirement issued at previous inspections remains outstanding but the home has nearly completed this. A number of maintenance issues were identified at the inspection and the Registered Provider contacted the maintenance man to address them immediately. What the service does well: What has improved since the last inspection? What they could do better: Once the home has received their medication trolley all medication will be stored securely at all times and during the administration procedure. Records of all medication including creams must be maintained. Four Seasons Version 1.10 Page 6 The home needs to complete regular safety checks on the pre set valves to ensure the hot water is delivered at a safe temperature so as not to put service users at risk of scalding. Regular water checks on their stored water are needed to ensure the home is reducing the risks of Legionella, and to ensure service users are not put at risk. The home must review their fire signage to ensure the safety of service users. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Four Seasons Version 1.10 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 Four Seasons Version 1.10 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 The homes Statement of Purpose and Service Users Guide provides prospective service users with details of the services offered. EVIDENCE: The home displays a copy of their Statement of Purpose in the main entrance to the home. An amendment is needed to reflect the changes in the management structure. The Statement of Purpose is available in large print. Four Seasons Version 1.10 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 standard(s) 9 & 10 The home has made good progress with regard to arrangements for administration of medication. The staff respect service users privacy and dignity, by knocking on their door prior to entering and addressing the service user with their preferred form of address. EVIDENCE: The home has nearly addressed an outstanding requirement relating to safe administration of medications. The home purchased a trolley but it was not big enough to contain all the medications. A new trolley is due to be delivered shortly, and in the mean time the staff are using a lockable box to transport medication around the home. The medication policy should be amended to include the importance of staff using the MAR (medication administration record) as part of the administration process. A record of the quantity of medication received was not documented on one MAR sheet, however the Deputy Manager said this is not normal practice. Medication should not have written on the label ‘as directed’ as this is not a clear instruction for use. One service user had a cream prescribed, but staff Four Seasons Version 1.10 Page 10 had not signed to say when it was administered, this information must be recorded as evidence the cream is being given and for stock control purposes. One service user has a ‘prn’ medication and the home has written a care plan for this. Specimen signatures list, medication information leaflets, fridge temperature are all in place. Accredited training has been provided for all staff that administer medication. Service users said the staff respects their privacy and dignity and gave examples of, staff knocking on their door prior to entering their room and addressing them with their preferred form of address. Four Seasons Version 1.10 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 standard(s) 15 The meals in the home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Service users and food records confirmed that the meals offered by the home are appealing, wholesome and varied. Choices are normally offered at each meal. A number of service users said they could chose to have their meals in the dining room or in their own rooms, and felt this was important. The cook said her food and hygiene training is out of date, but tends to rectify this by further training. Four Seasons Version 1.10 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 standard(s) 16 & 18 The home has a satisfactory complaints system with verbal evidence from service users that their views are listened to. The staff have knowledge and understanding of adult protection issues and thus provide a safe environment to protect service users from abuse. EVIDENCE: Records were seen of two complaints dealt with by the home. A copy of the homes complaints procedure is in the Statement of Purpose. Service users said they are able to discuss any issues/concerns they have with the management team. Staff said they have undertaken abuse training. A recent issue in the home demonstrated that the staff are aware of the whistle blowing policy and procedure. As the Registered Manager was away on holiday, training records for staff were not available. Four Seasons Version 1.10 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The standard of décor within the home is improving since the new Registered Provider took over. Now the home has proper maintenance input and a refurbishment plan, the whole environment will be greatly improved providing an attractive and homely place for service users to live. EVIDENCE: During the tour of the home a number of maintenance issues were identified and a list given to the home. The refurbishment of the lounge has greatly improved the room and all service users spoken with said how much better it looked. Plans are in place for further refurbishment of the home, the kitchen is next. The fire signage in the home appears to be lacking in places and one fire escape route was blocked, this was cleared during the inspection. The local fire service was contacted to give the home advice. The communal space consists of a dining room and a large lounge with a smaller room adjacent to this, that the home plans to use as an activities Four Seasons Version 1.10 Page 14 room. Several service users said they go out into the gardens when the weather is good. Ten rooms have en-suite facilities and assisted bathrooms are provided. Plans are in place to look at providing a shower room. A shaft lift provides access to the upper floor and other aids include, bath hoist, toilet frames, wheelchairs and handrails in corridors. Call bells are provided in service users rooms. Service users are able to bring in items of their own furniture and this was seen during the tour of the home enabling service users to individualise their rooms. Lockable facilities are not yet provided in all service users rooms. Three service users bedroom doors have frosted glass panels. Clearly these impinge on the service users privacy, and must be changed. The home must provide screening until they can replace the doors. Pre set valves have been fitted to hot water outlets used by service users but safety checks are not carried out to ensure they are delivering the correct temperature. Similarly work has been carried out to reduce the risk of Legionella, but without regular safety checks. A lock has been fitted to the laundry door and the floor titles replaced. Protective clothing is provided for staff when appropriate. The home is looking to fit a sluicing facility in the near future. Cobwebs were seen in two corridors and food debris was seen in several service users rooms, the home is looking to appoint another domestic to ensure a clean environment. Four Seasons Version 1.10 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 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 The staff have a good understanding of the service users needs and this is evident from the positive relationships which have been formed between the staff and service users. EVIDENCE: Duty rotas were seen and service users confirmed the staff meets their needs. On the day of the inspection the staffing levels were meeting the needs of the service users. The home is looking to appoint another domestic, to improve the staffing complement. Service users all praised the staff in the home saying they were friendly and helpful. Three staff have NVQ 2 training and 1 is due to complete soon and another is due to start. Two staff are due to start their NVQ 3. Four Seasons Version 1.10 Page 16 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) 33 & 38 The home is developing a quality assurance programme to ensure the needs and wishes of service users are being met. The management of the home ensure so far as is reasonably practicable the health and safety of the service users and staff EVIDENCE: The home has started to record monitoring systems used in the home. The Deputy Manager said questionnaires have been sent out to service users and their relatives but as the Registered Manager was away these could not be located. The Registered Manager on her return must ensure that all records required for inspection purposes are accessible to the management team. Policies and procedures were examined, and found to be reviewed on a regular basis. Evidence was seen of servicing of equipment, boilers and electrical systems. The home now has a clinical waste contract. Four Seasons Version 1.10 Page 17 The home needs have their wheelchairs and bath hoists serviced, the Registered Provider has this in hand. The risk assessment relating to the security of the home has been completed since the last inspection. Records need to be maintained when window restrictor are checked. Training records were not available as the Registered Manager was on holiday, these will be follow up at the next inspection. Four Seasons Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 2 2 2 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x x x 2 Four Seasons Version 1.10 Page 19 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 1 Regulation 4, 5 & 6 Requirement The home must amend their Statement of Purpose and Service Users Guide to reflect the changes in the management structure of the home. The Registered person must review the medication adminstration procedure to ensure the medication is stored securely at all times and MAR sheet are used as part of this process to recuce the risk of errors. Timescale of the 1/9/04 and 30/1/05 were not met. The home has nearly completed this requirement but had to return the first trolley ordered as it was not big enough. The home is waiting for their new trolley to arrive shortly. The Registered Person must address the following maintenance issues: 1) Secure the loose electrical socket to the wall in the corridor that leads to the rooms at back of the lounge. 2) The strip lighting in the identified service users room to be changed. Version 1.10 Timescale for action 1/6/05 2. 9 13(2) 15/6/05 3. 19 23(b) 1/7/05 Four Seasons Page 20 4. 19 23(4) 5. 24 12(4a) 6. 25 13(4a) 7. 25 13(4c) 8. 9. 26 9 23 13(2) 3)The doors to the sink cabinet in the indentified en-suites to be repaired. 4) The cracked window pane in upstairs corridor by room 21 must be replaced. 5) To repair the leaking tap in room 3. 6) To replace the broken toilet seat in the en-suite in room 2. 7) To repair the chipped sink top in room 5. 8) To replace light bulb in the upstairs airing cupboard. The Registered Person must review the fire signage in home inconjunction with the fire service to ensure the safety of service users. The Registered Person must change the 3 glass doors to the service users rooms to ensure their privacy and dignity is maintained. The Registered Person must undertake regular safety checks on all pre set valves to ensure they are delivering correct safe temperature to reduce the risk of scalding. Records must also be maintained of these checks. The Registered Person must undertake regular checks to ensure that the risks of Legionella are minimised. Records must also be maintained of these checks. The Registered Person must provide sluicing facilities. The Registered Person must maintain records of all medications given to service users. 1/7/05 1/7/05 1/7/05 1/7/05 30/6/05 20/5/05 Four Seasons Version 1.10 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. 2. 3. 4. 5. Refer to Standard 9 9 9 9 9 Good Practice Recommendations The home should write dates of opening on all liquid medications, creams, onitments, eye and ear drops. The home should get a second person to sign and check any hand written entries to reduce the risk of errors. The home should get all service users GPs to sign the homely remedy list as evidence of their agreement that those medications can be given to the service users. The home should not use the the instructions as directed on the MAR sheets as it could lead to errors and this should be altered to give proper instructions. The home should monitor the temperature of the room where the medication is stored at least daily and maintain reocrds of this information. Action should be taken if the room is above the recommended temperature for storage of medication and records maintained of the action taken. The home should provide lockable facilities for service users in their rooms. The home should undertake monthly checks on all pre set hot water outlets that are used by service users to ensure the water temperature is safe. The home should maintain records when window restrictors are checked. 6. 7. 8. 24 25 38 Four Seasons Version 1.10 Page 22 Commission for Social Care Inspection Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 Version 1.10 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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