Inspection on 05/04/07 for Four Seasons

This inspection was carried out on 5th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 16/03/06

Four Seasons 13/07/05

Four Seasons 13/07/05

Four Seasons 13/07/05

Four Seasons 13/07/05

Four Seasons 08/02/05

Four Seasons 08/02/05

Four Seasons 08/02/05

Four Seasons 08/02/05

Four Seasons 16/06/04

Four Seasons 16/06/04

Four Seasons 16/06/04

Four Seasons 16/06/04

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 Breightmet Fold Lane Bolton Lancashire BL2 5NB Lead Inspector Mike Murphy Unannounced Inspection 5th April 2007 09:30 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 DS0000005678.V298092.R01.S.doc Version 5.2 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 DS0000005678.V298092.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Four Seasons Address Breightmet Fold Lane Bolton Lancashire BL2 5NB 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) 01204 392005 01204 393005 www.schealthcare.co.uk Southern Cross Healthcare Services Limited Mrs Jacqueline Mellor Care Home 121 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (54), Old age, not falling within any other of places category (55), Physical disability (8), Terminally ill over 65 years of age (4) Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 121 services users, to include: up to 55 service users in the category OP (Older People) over 65 years of age; up to 54 service users in the category DE(E) (Dementia over 65 years of age), with 2 named service user (JR) and (MF) in the category of DE (Dementia under 65 years of age); up to 4 service users in the category TI (E) (Terminal Illness over 65 years); up to 8 service users in the category PD (Physical Disability under 65 years of age), within these, 2 places for named service users (BS and JC). A maximum of 29 service users in the above categories can receive nursing care. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 16th March 2006 2. 3. Date of last inspection Brief Description of the Service: Four Seasons is a 121-bedded care home providing a service to mainly older people, which include general nursing, dementia and residential care. The Home is also registered to provide care for eight younger people with a physical disability. The Home is situated on a bus route about 2 miles from Bolton Town Centre. The premises are purpose built on two levels with two lifts to the first floor. All bedrooms have en-suite facilities. Fee structure at the time of this inspection - from £355.08 to £557.00 per week (figures supplied by the home). Please consult the home for further details. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Four Seasons was inspected using information collected since the last inspection including information sent to us by the home, written comments from residents and their relatives, written comments from visiting health and social care professionals (for example doctors, nurses and social workers) and evidence gathered during an unannounced visit to the home by 2 CSCI inspectors. The visit lasted approximately 8 hours and included discussions with residents and their relatives, the manager and staff, visiting health care staff and inspection of the environment and documents relevant to the well being of residents and the way the home was being managed. What the service does well: What has improved since the last inspection? There have been environmental improvements in the home. In particular the redecoration and refurbishment of Spring unit (since the last inspection) has significantly improved the accommodation provided for the residents who reside there. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 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 DS0000005678.V298092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No prospective residents are admitted to the home without their care and support needs being assessed appropriately. EVIDENCE: Spring and Winter units Prior to residents being admitted to the home the manager or senior member of the nursing care staff carry out an assessment of the prospective resident’s needs in consultation with the resident, their relatives and relevant health (for example doctors) and social care professionals (for example social workers). The purpose of such an assessment is to assist the prospective resident (and their relatives) in their considerations of how appropriate a placement at the home would be and enable the nurse or care worker conducting the assessment to determine if the home will be able to meet the prospective resident’s needs appropriately. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 9 A statement of purpose and service users guide is provided and contains information that assists prospective residents and their supporters to make informed choices about the suitability of the home. Discussion with resident’s relatives revealed that the process of admission was dealt with sensitively and that they felt that they were consulted at all stages and also that their views were regarded as being important and that they felt they were part of the decision making process. The placement of all residents is subject to ongoing review and relatives reported they were included in these reviews. Autumn and Summer units. Inspection of 3 resident care files showed that before they were admitted to the home an assessment of their needs had been undertaken either by the manager or a senior member of staff. The resident files also had assessments undertaken either by the residents’ social worker or from the hospital they were admitted from. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care residents at the home receive appears to be suitable and appropriate and is meeting the expectations of residents and their relatives. EVIDENCE: Spring and Winter units These units provide care and accommodation for elderly residents who require such support because they are suffering from conditions that significantly impair their memory and ability to live independent lives safely. Both units provide EMI Nursing care. 6 residents care records were inspected – 3 from each unit. Care records were organised in a standard format on both units. All contained detailed pre and post admission assessments that clearly identified the care needs of residents. All areas of the resident’s life are considered in such Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 11 assessments including their physical, mental and social needs. All care records contained a life and social history of the resident. This enables staff to relate the care and support they provide to an individual resident who is a unique person and not just ‘one of many’. Care plans clearly identified how resident’s assessed needs (including their religious and cultural needs) were to be met by identifying exactly what actions and support needs to be provided to care for these residents properly. Care plans were formally reviewed at least monthly. Particular areas of risk are formally ‘risk assessed’ on a regular basis to protect resident’s health and safety. Examples of such risk assessments included those completed in relation to preventing pressure sores, mobility and moving and handling and nutrition (including regular weight monitoring). All residents are registered with a local GP and it was evident that all were enabled to access opticians, chiropodists, district nurses and other specialist services that individual resident’s require (such as community psychiatric nurses and psychiatrists). It is noted that there are sometimes difficulties securing dental services by residents – this is being pursued by the home manager. Relatives spoken to (and in pre inspection questionnaire responses) indicated they were kept informed of all significant changes in their relation’s health. The management of residents medicines was inspected on Spring unit on this occasion. The procedures for the receipt, recording, storage, handling, administration and disposal of resident’s medicines were appropriate and safe. The qualified nurses on Spring and Winter units are responsible for all aspects of looking after resident’s medicines who are under their care. Medicine records inspected had been completed properly. Discussion with relatives and staff revealed that residents were treated with respect and that their right to privacy was upheld. Comments made included; ‘the staff are nice and polite’, ‘I have been asked what my relative’s likes and dislikes are’, ‘the residents always look like they have been cared for properly whenever I have visited – which I do often and at various times of the day’, ‘the doctors examine all our residents in their own bedroom’. During the inspection staff treated residents with respect, in a nice manner, protected their dignity and assisted them properly. Autumn unit This unit provides care and accommodation for residents who require ‘personal’ or ‘residential care. The care plans of 3 of the residents were looked at. They contained a lot of information about how to care for the residents. The physical and social assessment for one resident was very detailed however this assessment was not signed by whoever had undertaken the assessment, and neither was it dated. Some other documents for this resident were also not signed or dated. If a document is not dated, it makes it extremely difficult to know over what period of time there may have been a change in their condition. The physical and social assessment for another resident was not completed fully. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 12 1 of the care plans showed that the resident had 2 pressure sores. The Inspector was told that resident was being cared for on a pressure-relieving mattress but this was not written in the care plan. The care plan showed in great detail what the district nurses were doing to heal the pressure sores but the staff on the unit had not written a care plan to show how they were preventing pressure sores from forming or from getting worse. The manager and senior carer agreed to write a care plan for pressure sore prevention that day. Summer unit This unit provides care and accommodation for residents who require ‘general nursing care’. 1 of the residents had pressure sores and the care plan had detailed information about the care of them and a good care plan for preventing pressure sores from forming or from getting worse. The home had also sought the advice of a nurse who specialised in wound care. Another resident also had pressure sores and a good plan of care was in place for their care and prevention. The staff on Autumn and Winter units looked at whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems with their diet and fluid intake. These are called risk assessments. Both units were using a special diet risk assessment (called MUST which stands for Malnutrition Universal Screening Tool) that is gradually being introduced by the local dieticians. This risk assessment gives a much more accurate picture about whether a resident could be at risk of malnutrition. The staff spoken to on Autumn Unit had not however received the proper training to show them how to use it. The manager told the Inspector that the need for training had been recognised and training was going to be given very soon. Staff also assessed if it was safe to use bed rails and looked at any other general safety risks. Risk assessments were in place for whether a resident was at risk of falling. They also looked at and they wrote down, how any resident was to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. From the care plans inspected it was evident that the residents were weighed at least on a monthly basis and any weight loss identified and acted upon. Equipment necessary for the prevention and treatment of pressure sores was readily available within the home. Inspection of the care files showed that the residents had access to health care professionals, such as district nurses, dentists, opticians and chiropodists. The inspector spoke with a visiting district nurse on Autumn who told her that the staff were very good at informing the district nurses if they felt there was any problem. She also said that the staff followed their advice and guidance properly. One resident on Summer said to the Inspector “ You would be hard pushed to find anything wrong here”, a resident from Autumn said “The seniors are Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 13 excellent but the younger ones are not as good,”2 relatives on Autumn told the Inspector that they felt the staff were “excellent”. The management of residents medicines on Autumn unit were inspected on this occasion. A safe system of medicine management was in place. The medicines were securely stored in a locked room and the medicine trolley was secured to the wall when not in use. Controlled drugs were securely stored, safely administered and accurately recorded. All staff, responsible for giving out medication, had received the proper medication training. The areas in need of putting right were as follows: A medicine that was not a controlled drug was being stored in the controlled drug cupboard. A handwritten instruction for medicines (Transcriptions) was not checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors. The date of opening was not written on 2 bottles of eye drops. It is important to do this so as they have to be thrown away 4 weeks after opening. None of the residents on Autumn were responsible for taking their own medicines, apart from 1 person who used a spray when needed. Staff told the Inspector that on admission they did not routinely ask people if they wanted to take responsibility for their medicines. Staff agreed to look at this and then when somebody wanted to keep and give their own medicines the staff would do a risk assessment to see if it was safe to do so. Residents on Autumn and Summer units looked clean and comfortably dressed. Staff were very discreet when helping the residents to move around the home. Staff spoke to the residents in a very respectful way. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are able to enjoy a stimulating lifestyle with a variety of options to choose from. The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. EVIDENCE: All units The home continues to provide a wide programme of social and leisure activities. Residents from each unit are enabled to become involved in the varied group activities provided. A programme of activities and events was prominently displayed in the home – this enables residents to be aware what is available and to choose what activities they wish to participate in. The programme of activities includes entertainers coming to the home and a variety of outings that provide opportunities for residents to enjoy life and leisure in the wider community. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 15 Residents and their relatives said that there were no unreasonable restrictions to visiting at the home. Relatives said they were made welcome when they visited and that they were kept informed of changes or developments in the condition of their relative. Residents spoke very positively in respect of the food provided for them by the home. Menus are balanced and provide a varied diet and choice. Resident’s meals are prepared on site. Breakfast and Lunch were observed during the inspection. At both meals residents were served and assisted appropriately and the food provided was well presented and sufficient in quantity. Residents consulted commented positively about these meals. Comments included – ‘the meals are really quite good and I always have enough to eat’, ‘you can always ask for something different if you don’t like a particular selection’, ‘I am able to eat myself but the staff help those who can’t’, “the food is excellent” “The food is very good. “I am very fussy but I dont leave anything”. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives spoken to felt comfortable enough to and knew how to make a complaint if they felt it necessary. Written guidance and training arrangements ensure that staff members have a good knowledge of abuse and protection arrangements and safeguards are in place to protect the welfare of residents. EVIDENCE: All units The complaints procedure was prominently displayed and also is available in the ‘Service users guide’ that is provided for resident’s and their relative’s information. Relatives said that any concerns or worries brought to the manager’s attention are responded to quickly and rarely become formal complaints. A complaints log is maintained. Complaints and incidents are managed appropriately. Four Seasons operates protection of vulnerable adults and whistle blowing policies that seek to protect elderly people. In addition, a copy of Bolton’s Inter agency protection procedure is held on site. Staff spoken to confirmed that they had received adult protection training (this was reflected in training records maintained by the home) and were aware of the whistle-blowing policy. Appropriate pre-employment checks are conducted on all staff to ensure suitable people look after the resident’s. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home appeared to be structurally well maintained throughout and provides a suitable and comfortable environment for the care of residents. EVIDENCE: Spring and Winter units Spring unit was in a good state of repair and decoration throughout – it is noted that this unit has been redecorated and refurbished since the last inspection in March 2006. Work on redecorating and refurbishing Winter unit was due to commence shortly after this inspection. Communal lounge and dining areas were clean, suitably heated, comfortably and appropriately furnished and provided a suitable and secure environment for resident’s to be cared for and supported properly. Appropriate provision of televisions, music centres and other leisure equipment has been made. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 18 Residents are also supported – when the weather is suitable - to access the pleasant garden areas within the grounds of the home. Appropriately adapted bathing/shower areas are provided. The home has generally been suitably adapted to meet the needs of residents in relation to specialist equipment. Individual resident’s specialist needs are met following referral of the individual resident to the relevant health care professional. Resident’s bedrooms that were inspected were very clean, suitably furnished and equipped and in a number of cases very personalised. All bedrooms are provided with en-suite WC and washbasin. Both units were clean and free of malodour at the time of this unannounced inspection. Suitable arrangements and equipment were in place to manage the laundry requirements of residents at the home. And appropriate measures were being taken to minimise the potential spread of infection within the home. Autumn & Summer units The Inspector looked at several bedrooms, the lounges, the dining rooms bathrooms and toilets. The lounges and dining rooms were clean warm, suitably heated and nicely furnished. There were enough toilets and bathrooms to meet the needs of the residents. Toilets were close to bedrooms and lounge and dining rooms. Each bedroom also had an en-suite toilet and washbasin. Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were clearly marked. The toilets and bathrooms were clean and were suitably adapted for disabled use. Several of the en-suite toilets, toilets and bathrooms did not have a lead attached to the call bell system. To make sure that the residents are safe and can call for help, a call bell lead must be in place. The bedrooms were clean, warm and suitably furnished. All the bedroom doors had an overriding door lock in place and they all had a lockable space. 1 resident showed the Inspector that he had a key to his door and to his lockable drawer. The Inspector saw that many of the bedroom doors had been wedged open. This is a fire hazard. The Inspector discussed this concern with the manager and a visiting regional manager and they agreed to look into safe ways of keeping the doors open. The heating within the home was adequate. All the rooms were centrally heated with radiators that were protected. The units were clean and free from odours. Hand washing facilities were in place in bedrooms, bathrooms and toilets. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment, provision and training of staff employed at the home are being managed appropriately. This is important to ensure that residents are being cared for adequately and appropriately by staff who are able to deliver this support safely and competently. EVIDENCE: All units Examination of the duty rotas and a discussion with staff, relatives and residents showed that there was enough staff on duty to meet the residents’ needs. The staffing rota on Summer did not have the full names of the staff written down. So that there is always a true record of who is or was on duty, the full names need to be on. Inspection of 3 staff personnel files revealed that these contained an application form (including health declaration), 2 written references, a Criminal Records Bureau check (including a ‘POVA first’ check), proof of identity and evidence of induction training and further training. NVQ training in health and social care is being provided for staff. Also a wide range of appropriate and ongoing training in moving and handling, abuse, Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 20 basic food hygiene, fire safety and other relevant topics are provided to staff at the home. Training provided to individual staff is recorded in detail and reviewed at frequent intervals. Staff spoken to felt their training needs were being addressed. And many felt this made them more competent and felt more valued in their work. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Four Seasons is being effectively managed by the very experienced registered manger- a qualified registered nurse with wide experience in general nursing/management and care of the elderly. EVIDENCE: The registered manager has the required qualifications and experience and manages the home in such a way that strives to meet the aims and objectives of the home. A deputy manager and administrator support the manager in her role. A senior management team appointed by the company who own and operate the home also provides support. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 22 Discussion with residents, their relatives and staff indicate that the manager is highly visible in the home and operates an ‘open door’ policy that enables any issues to be easily discussed with her. Those spoken to felt comfortable to do so. Residents, their relatives and staff can also affect the way services are delivered at the home at the more formal regular meetings that are held for these groups - a relatives meeting was arranged and being held during our unannounced inspection. Management policies – for example for the recruitment of staff – are effectively implemented and monitored. The inspectors are of the view that the home is run in the best interests of the residents. The manager operates procedures that seek to ensure the quality of the service provided is good – and where it is identified as not being up to standard takes appropriate action to rectify the situation. The manager and her deputy regularly conduct formal audits of various aspects of systems and procedures operated by the home. For example residents care records are periodically checked to ensure they properly reflect the care and support needed by residents and also demonstrate care and support is delivered. The registered manager’s area manager also visits the home periodically and conducts her own audit of the home. Measures were in place to ensure that residents’ financial interests are safeguarded. Residents are encouraged to control their own money. However where they are unable (or choose not to) personal allowances are managed by the home. The arrangements for this were secure, appropriately documented and are regularly audited by the area manager responsible for the home. The health, safety and welfare of residents and others are promoted and protected. For example staff are provided with regular training and appropriate equipment to ensure resident’s moving and handling needs are met – and example of this would be for a resident who needs to be safely moved with the aid of a hoist. Fire safety training is regularly provided – however there is an issue regarding bedroom doors being wedged open on Summer and Autumn units – as referred to earlier in this report. Documentary evidence was seen of gas and electrical safety inspections/servicing. The premises were secure at the time of this unannounced inspection – although there had been recent issues regarding the security of the main door leading into the home that had been eventually rectified. Hot water temperatures were being monitored regularly and the inspectors were informed all immersion baths/showers are fitted with devices that are intended to prevent burns. The passenger lifts that enable residents and others to access all areas of the home have been serviced as has all hoisting equipment used in the home. All significant events in the home – including accidents and illness and monitoring visits by the home’s owners – are recorded and reported (as required legally) to the CSCI. Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 2 Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(1) Requirement You must make sure that a care plan for pressure sore prevention is in place for any resident who has or may be at risk of, developing them. Only controlled drugs are to be stored in the controlled drug cupboard. Timescale for action 31/05/07 2. OP9 13(2) 31/05/07 3 OP24 13(4)(a) To reduce the risk of accidents 31/05/07 and make sure that residents and staff can summon assistance in an emergency, call bell leads must be in place in all resident areas, especially toilets and bathrooms. Bedroom doors must not be 31/05/07 wedged open. If bedroom doors need to be kept open you must look at a safe system for that will comply with the requirements of the Greater Manchester Fire & Rescue Service. You must inform the CSCI (in writing) that the redecoration/refurbishment of DS0000005678.V298092.R01.S.doc 4. OP24 OP38 23(4)(a) 5, OP19 23(1)(2) 31/05/07 Four Seasons Version 5.2 Page 25 Winter unit has been completed. 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 3. Refer to Standard OP7 OP8 Good Practice Recommendations You should make sure that staff sign and date care documentation. If staff are to use the MUST nutritional screening tool they should have the correct training so that it can be used properly. To ensure the accuracy of a handwritten transcription they should be checked with another member of staff, signed and countersigned The date of opening should be written on bottles of eye drops. It is important to do this so as they have to be thrown away 4 weeks after opening. Standard 9. As part of the admission procedure staff should do a risk assessment to see if a resident wants to, and is safe to look after their own medicines. To ensure that the duty rota gives a clear record of who is, or has been on duty, the staffs’ full name should be used. 4. OP9 5. OP9 6. OP9 7. OP27 Four Seasons DS0000005678.V298092.R01.S.doc Version 5.2 Page 26 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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