Inspection on 28/11/05 for Four Seasons

This inspection was carried out on 28th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Four Seasons 02/01/07

Four Seasons 25/04/05

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 Glos GL55 6SJ Lead Inspector Sharon Hayward-Wright Unannounced Inspection 28th November 2005 10:30 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 DS0000061877.V268112.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 DS0000061877.V268112.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Four Seasons Address Back Lane Mickleton Nr Chipping Campden Glos GL55 6SJ 01386 438300 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) Four Seasons Mickleton Limited Tracey Jayne Elizabeth Jary Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2005 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. The ground floor communal areas provide a separate lounge and dining room. 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 DS0000061877.V268112.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 over 5 hours on one day in November 2005. Four service users were spoken with to gain their views on the home; the care of two service users was examined in detail and four staff members were also spoken to, as well as the Registered Manager and Registered Provider. Staff were observed going about their duties and interacting with each other and service users. The requirements and recommendations made at the last inspection were followed up and records relating to the homes’ Statement of Purpose and Service Users Guide, service users care, activities, medication, staff personnel files and supervision were inspected, and a tour of the home took place with a number of service users rooms inspected. This is the first inspection with the new Registered Manager, the home continues to make great improvements and at this inspection they only received one requirement and a small number of recommendations. This is excellent and the staff should be commended on their hard work. All service users made positive comments about the home. What the service does well: The home provides service users with a wholesome diet offering service users a choice and meeting any special dietary needs. Some of the staff have been working at the home for a number of years resulting in consistency for service users. The staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. The staff have a very good understanding of the needs of the service users. The homes activities programme offers service users the opportunity to satisfy their interests and needs. Links with the local community are encouraged and visiting to the home is flexible to meet the needs of service users families and friends. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 6 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. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 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 DS0000061877.V268112.R01.S.doc Version 5.0 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): 1, 3 & 5 Arrangements are in place to ensure prospective service users and their family/representatives can feel confident that the needs of the service user will be met on admission to the home. EVIDENCE: The home has addressed the requirement issued at the last inspection to amend their Statement of Purpose and Service Users Guide to reflect the changes in the management of the home. A recently admitted service user’s pre admission assessment was examined and found to be very comprehensive. A copy of Social Services care plans and hospital discharge information was present. The service user and records confirmed that the service user visited the home prior to admission. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 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, 9 There is a clear are planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. Service users are able to have their health needs met. The systems for administration of medication are good with clear arrangements being in place to ensure service users medication needs are met. EVIDENCE: Two service users had their care examined in detail and five other care plans were also examined. The care plans seen had an assessment of needs and from this, care is planned. Individualised care plans are in place. The home also uses a dependency score and residents profile. One of the service users whose care was examined in detail was displaying a change in behaviour since being discharged from hospital. The Registered Manager said the GP is due to visit today and following this visit the care plans will be reviewed to show the changed in behaviour. Evidence was seen of reviews in care plans but the timing varied some were reviewed monthly and others two monthly and some were said to be reviewed monthly but this was not happening. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 10 It is recommended that all care plans be reviewed monthly. Daily records are maintained. Staff spoken with all demonstrated a good understanding of service users care needs. Evidence was seen in the care plans of health professional visits. Moving and handling assessments and nutritional risk assessments were completed on all service users whose care plans were looked at. Medications were not examined in detail at this inspection only the requirements and recommendations made. The requirement to review their medication procedure is now completed. Of the five recommendations made three remain outstanding, however one of these is part way to completion. Four Seasons DS0000061877.V268112.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): 12, 13 & 14 The homes activities programme offers service users the opportunity to satisfy their interests and needs. Links with the local community are encouraged and visiting to the home is flexible to meet the needs of service users families and friends. EVIDENCE: The home has an activities coordinator who organises activities on set days of the week. The type of activity varies depending on the service users involved. Outside entertainers also visit the home. Activities questionnaires have been completed on all service users. Service users spoken with said they are able to undertake their own activities or join in the ones provided by the home. The home is looking to arrange training for the activities coordinator. The home now has a monthly newsletter that is sent to all service users. Service users and the Registered Manager confirmed that visiting is flexible. Service users where able are encouraged to go out in to the local community. The home has a notice board containing information for service users, for example advocacy information, the newsletter and the weather and date for that day. Service users said they are able to make choices over their daily lives. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 12 Food was not inspected but service users all praised the food provided. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 13 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): No standards were assessed at this inspection. EVIDENCE: Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 14 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): EVIDENCE: No standards were assessed in full only the requirements and recommendations made at the last inspection. All requirements have been met. One requirement to change three glass doors has not been undertaken. The reason for this is that one service user feels their room will be dark. Coverings have been applied to the doors and a further blind will be added to this service users room to ensure their privacy but also giving them the option to retain the light when the blind is not needed. Of the two recommendations made one is still to be met and the other is partly met as the home replaces furniture; lockable facilities are being provided. The other is to undertake monthly checks on all pre set hot water valves used by service users to ensure the water temperature is safe. The Registered Provider is still in the process of refurbishing the home. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 15 The downstairs toilet by the side entrance has a cork floor and on this was visible water damage. This needs to be replaced, as it is an infection control risk. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 16 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): 28, 29, & 30 Since the last inspection the standard of vetting and recruitment practices has vastly improved with all the appropriate checks being carried out to prevent any service users being put at risk. The staff demonstrated good awareness of their roles and responsibilities, however it was difficult to evidence whether training was up to date. EVIDENCE: NVQ training for staff was examined; three care staff have NVQ 2 training and four are in the process of completing this. Three care staff are working towards NVQ 3. Five new staff personnel files were examined; all of these had the required information present for example two written references, with one from the last employer, full employment history and POVA/CRB (Protection of Vulnerable Adults and Criminal Records Bureau) checks. It is recommended following the revised Data Protection Act the POVA/CRB checks are stored separate but secure from staff personnel files. Interview records and an exit interview from a member of staff who has left the home, were seen. As the home is exceeding the standard, a score of 4 has been awarded at this inspection. As the Registered Manager has not been at the home very long, she is in the process of updating the training matrix to ensure the staff are up to date. This will be followed up at the next inspection. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 17 An induction checklist was seen in a new member of staff’s personnel file. It is recommended that the home check that this meets the National Training Organisations specifications. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 18 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, 32, 33, 35, & 36 Since the last inspection the home has had a change of Manager, which has resulted in consistency with practice and record keeping. The Manager is able to discharge her responsibilities in full and service users can feel confident that the home is run in their best interests. EVIDENCE: The Commission for Social Care Inspection has recently registered the Manager of the home. She is a qualified nurse and has completed the NVQ 4 training. The Registered Manager is aware of the importance of keeping herself updated. Service users and staff all said the Registered Manager and Registered Provider were approachable and would listen to any concerns they have. Minutes of staff meeting were seen. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 19 The home has recently sent out questionnaires to service users and the results of these are published in the monthly newsletter. The home now needs to look at monitoring systems to ensure the home is meeting the needs of the service users. Ways to achieve this were discussed at the inspection. This will be followed up at the next inspection. Policies and procedures will be reviewed shortly with the other care home operated by the Registered Provider to ensure consistency. The home has secure facilities for storing service users monies; only one service user uses this facility. The appropriate records were seen. The Registered Manager and Registered Provider are not appointees or agents for any service users. The Registered Manager has reviewed the staff supervision arrangements. The Registered Manager has started this process and is looking for the senior care staff to supervise the other care staff. Records were seen of supervision and the Registered Manager is looking at providing supervision for non-care staff. A recommendation made at the last inspection for the home to maintain records of checks on window restrictors, is yet to be addressed. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 20 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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 x x x x x 2 x STAFFING Standard No Score 27 x 28 2 29 4 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 3 x 2 Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? no 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 OP19 Regulation 13(3) Requirement The home must replace the cork flooring in the downstairs toilet by the side entrance, as it is an infection control risk. Timescale for action 10/01/06 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 2. 3. 4 Refer to Standard OP7 OP9 OP9 OP9 Good Practice Recommendations The home should review all care plans monthly. 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 monitor the temperature of the room where the medication is stored, at least daily, and maintain records 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 undertake monthly checks on all pre set hot water outlets that are used by service users to ensure DS0000061877.V268112.R01.S.doc Version 5.0 Page 22 5. OP25 Four Seasons 6 7 8 OP29 OP30 OP38 the water temperature is safe. The home should store staff CRB/POVA checks securely but separately from their personnel files. The home should ensure that their induction programme meets the National Training Organisations specifications. The home should maintain records when window restrictors are checked. Four Seasons DS0000061877.V268112.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Gloucester Office 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 DS0000061877.V268112.R01.S.doc Version 5.0 Page 24 - 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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