Inspection on 07/03/06 for Four Seasons

This inspection was carried out on 7th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Four Seasons 13/03/09

Four Seasons 12/03/07

Four Seasons 30/12/04

Four Seasons 21/07/04

Four Seasons 29/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Four Seasons 77 The Wood Meir Stoke-on-Trent Staffordshire ST3 6HR Lead Inspector Peter Dawson Unannounced Inspection 7th March 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Four Seasons DS0000008231.V285827.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 DS0000008231.V285827.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Four Seasons Address 77 The Wood Meir Stoke-on-Trent Staffordshire ST3 6HR 01782 336670 01782 343133 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) Day Care Services Limited Lynne Chetwynd Care Home 22 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (22), of places Physical disability over 65 years of age (7) Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th December 2004 Brief Description of the Service: Four Seasons is a detached property, in a semi-rural setting in Stoke on Trent (south). It was opened in 1990 for up to 8 service users and two years later extended to accommodate up to 17 people over 65 years. Six months ago a further extension was completed increasing the number of beds to 22. The new extensions provides additional bedrooms, spacious and excellent lounge facilities, conservatory and additional dining room. All but 2 bedrooms have en-suite facilities. Two bedrooms are for shared use. There are now 3 lounges, 2 separate dining areas and conservatory. The first floor is accessible by staircase and shaft lift. Nursing care is not provided. The home is afamily run business, which has been built upon its reputation for providing good quality care in a homely atmosphere. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this unannounced inspection there were 20 people in residence (including 1 in hospital). There were 2 vacancies. Most residents were seen and the majority spoken to together or separately and in private. One visiting relative was seen. All residents spoke highly of the care provided at Four Seasons. They confirmed that staff were attentive and caring, that their likes and dislikes were known and respected. All were satisfied with food provision and there were no complaints. A visitor of recently admitted resident said that she was highly satisfied with the admission procedures to the home and that staff had been helpful in helping her mother settle quickly into the home. The extension to the home was completed 6 months ago and provides excellent facilities. It is unfortunate that the excellent conservatory area is unused and further efforts should be made to encourage residents to use this facility. There was an inspection of the environment including the communal areas and sample of bedrooms. Standards were high and bedrooms had good facilities and were used during the day as residents wished. The laundry and kitchen areas were not inspected. Standards of furnishing and décor were high with equal standards of hygiene and cleanliness. Four new residents admitted to the home were seen and spoken said that they had settled quickly and well into the home. The exception was a lady with dementia care needs who was taking longer to settle into the home and made repetitive reference to alternative accommodation the type of which was not clear. The home does not have category to admit people with mental health needs (MD category). Two people appear to fall into this category at this time and the home are advised to consider an extension of their registration categories to include this. The home appeared well run and managed and provides a good standard environment with a committed staff group. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? The new extension providing 6 additional single bedrooms with en-suite facility, new lounge and conservatory and additional dining option. A walk-in shower area provided on the first floor. With the exception of the conservatory all areas are now in use. The ground floor corridor areas and dining area have been redecorated and recarpeted. Certain fire doors identified have been adjusted to ensure they close onto the recessed area of the frame to ensure safety. The staffing complement has been increased in line with increased numbers of residents. The recording of activities in the home has improved and activities increased in relation to need. The lino in an en-suite facility has been removed and replaced with carpet. Staff entries on care records are all signed. Some areas of recording personal care have been improved. Staff have received instructions in relation to adult abuse and training course being sourced. An office is being vacated by the domicillary care service which will give required additional office space. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 7 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 DS0000008231.V285827.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1–5 Standards relating to Choice of Home were found to be met. EVIDENCE: The Statement of Purpose/Service Users Guide has been updated since the last report to reflect the changes provided in the service. A revised copy of the Service Users Guide is available to residents in all bedrooms and the Statement of Purpose is available in the home for all residents/visitors. Information in those documents provide prospective residents and their families wituh the information they require to make an informed decision about the suitability of the home. Records and discussions with new residents and their relatives showed that prospective residents were always invited to the home prior to admission and relatives/supporters similarly invited. Residents are always seen in their current environment if they are unable to make pre-admission visits. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 10 The relative of a recently admitted resident said that her mother had declined to visit the home prior to admission but that all 5 children had visited to view and assess the suitability of the home for their mother. The homes own pre-admission assessment had been provided prior to admission. The home were advised to include a history of falls in their assessment. A Care Management Assessment/Hospital Social Assessment were also provided in each case. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 11 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 - 10 Previous recommendations relating to care records have been adequately addressed. Care plans contained all required information to identify and meet needs. There is a pro-active approach to health care issues confirmed in tracking. The inputs and records relating to a highly dependent resident were to a very high standard. Medication records were completed accurately and signed as required. The home should review its agreed categories of registration to include people in MD category. Provision of anti-psychotic medication in relation to a resident identified should be swiftly reviewed with the GP. Continence aids must not be displayed in bedrooms. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 12 EVIDENCE: A sample of care plans were inspected during this visit. They were found to be based upon the assessed needs of residents including the Care Management Assessment and the homes own pre-admission assessment. One included a resident who had been provided with a domiciliary care service provided by an associate company of the homes providers. Care plans provided adequate information to provide care in relation to the health, social and emotional and recreational needs of residents. Three recommendations were made at the time of the last report in relation to care records and have been addressed: All records are now signed by staff and all indicated the level and frequency of interventions. The storage of personal information had reached capacity but space is being provided with an additional office which is being vacated in the next few weeks by the Domiciliary Care Service allowing expansion for records and also increased confidentiality. Risk assessments were seen and had been adequately completed and were reviewed on a regular basis. Provision of a lap strap for resident in a wheelchair had been made following falls from the chair and consultation with the relatives. Verbal agreement had been obtained and confirmed written consent will be obtained on the next visit by the relative. The resident was seen and seemed comfortable with the provision for her safety. There are daily notes for each resident which were completed concisely and appropriately. Night checks were recorded satisfactorily with hourly checks for all residents and half-hourly for a totally dependent resident and for new residents until their sleeping patterns had been established. There was a focus upon health care provision by the home. A resident with resistant infection was being seen by the visiting GP on the day of inspection. A resident admitted recently required administration of oxygen for up to 15 hours per day. This was a new scenario for the home who had taken advice from the hospital specialists and pharmacist in its provision and storage with attention to safety aspects. This was adequately documented in the care plan with clear instructions to staff. The Fire Office had been contacted and his advice actioned in relation to safe storage. District Nurses are visiting only in relation to the usual routine checks. In relation to a wheelchair-bound resident with oedema they had ceased visits but available upon request from staff if there were any concerns or advice was needed. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 13 In relation to a bedfast, totally dependent resident the nursing service had been visiting to monitor pressure areas but these had healed and visits no longer required. The records were seen in relation to this resident who remains on an alternating pressure-relieving mattress and is turned on a 2 hourly basis as stipulated. Records are kept in the residents bedroom and all staff record the 30 minute checks throughout the 24 hour period and include turning actions, inputs of all drinks/liquidised foods/supplements. Additional funding is provided for this person, but the inspector was particularly impressed with both the care being provided to this totally dependent person and the detailed recording of information. Due to registration difficulties with local GP practices a total of 7 separate GP practices provide a service to the home. Fortunately the operation of district nursing service has recently been changed from a GP practice-based service to a flexible overall service. This allows continuity and simplification of access the nursing and other health care services. Residents visit the GP surgery if possible but home visits are requested if required. There is a hoist used presently for one resident. This is serviced on a 6 monthly basis. Staff have received Moving & Handling training, including the use of the hoist from an approved trainer based at the other home in the same ownership. However the Manager at Four Seasons has recently completed a trainers course allowing her to train all staff in Moving & Handling – updates and necessary training will now be ongoing. Medication is provided by local pharmacy in MDS form (Nomad). Records relating to medication were examined and MAR sheets had been completed accurately as required. The medication cupboard had not been refixed to the wall following recent re-carpeting of the room – this was done during the inspection by a proprietor. Evidence of anti-psychotic prescription indicated that 2 residents who were being seen by Consultant Psychiatrist were in the MD (Mental Disorder) Category, for which the home do not have category to admit. It appeared that this condition had manifested following admission, but it is recommended that the home may consider application for additional categories of admission to include MD. Admissions under that category are meanwhile not allowed. Discussion with the Manager concerning provision of Haloperidol for another resident agreed that this may be inappropriate and would be discussed with and reviewed by the GP at the earliest opportunity. In relation to privacy and dignity, screens were seen to be provided in shared bedrooms (and reported to be used), there were locks on bathroom/toilet areas ensuring privacy. There was a large supply of continence aids in a bedroom which should be removed to preserve dignity. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 – 15 There were examples of chosen lifestyles being accommodated. Residents were generally satisfied with the services provided. Recording of activities has improved and there appears a range of activities on a small group or individual basis to meet the needs of most residents. Visitors confirmed they were welcomed into the and kept informed of any changes. Some residents go out with relatives wherever possible. Residents expressed satisfaction with food provision. EVIDENCE: Chosen lifestyles were discussed with residents who were satisfied with the routines in the home which they said supported their chosen lifestyles. A discussion with one resident giving some conflicting information relating to this was referred to the Manager to discreetly pursue. Several residents rise early which they confirmed was their preferred option. About half the residents had finished breakfast upon the arrival of the inspector (9.10a.m.) the remainder seen to arrive later in the dining area for breakfast. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 15 Some residents said they had early morning tea in their bedrooms (not wakened unless requested to do so), others preferred to come to the lounge/dining areas. Breakfast seems to be served from 8 a.m. perhaps some residents who choose to rise early have to then wait until 8 a.m. In contrast to this one resident who chooses to remain in her bedroom only visiting the lounge areas when entertainment is provided – has all her meals served in her bedroom. At the time of the last inspection it was felt that records did not give a clear picture of the level of activities provided in the home. The Manager has reviewed the recording system for this and records seen showed a more accurate reflection of the activity level. Staff engage in daily activities in the home with residents and there are many examples of 1:1 interventions which are required. These are now recorded. Staff meeting records showed that the lack of recording had been brought to the attention of staff and improvements sought and actioned. The list of activities given included: shopping trips, bingo, reminiscence, bowls, hoopla, quizzes etc. Specialist large form games have been purchased which are age-appropriate. Discussions with some residents showed that certainly the more mobile/able residents were taken out on short shopping trips etc by staff- usually one or two at a time with a staff member. There was in fact an example of a member of staff taking a resident out on a weekly basis by a staff member in her offduty time. There is a dedicated hairdressing salon with excellent facilities used by the weekly visiting hairdresser. Involvement of family/friends in the lives of residents are considered part of the care process. A visiting relative confirmed this and said that 5 members of her family were regular weekly visits to the home. They were welcomed into the home by staff and comfortably moved around the home. She confirmed that she was kept informed of any changes affecting the health and welfare of her relative. The TV was on quite loudly in a lounge area at 9a.m. with no-one watching it. It was difficult to have a conversation with a resident with excellent hearing. The manager is asked to review this procedure, although in contrast later in an inner lounge, background music was playing encouraging social exchanges and peace. The extensions to the home, completed 6 months ago have provided additional high quality accommodation. This includes a new lounge and also a large attractive, well-equipped conservatory with panoramic views of the side and rear garden area. This room was unused and the heating not switched on. The Manager said that residents had been encouraged to use this lounge but without success. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 16 The majority of residents were sitting in a small rectangular lounge area with one window with no external view when seated. Chairs were placed around the perimeter of the narrow lounge area. It is recommended that the heating be resumed to the new conservatory area and further efforts made to encourage/persuade residents to use the superb facilities of that area which have been provided at great financial cost and to enhance the communal facilities. The kitchen facilities were not inspected on this visit. All residents spoken to said that the food provided was to a high standard, that the quality and quantity of food was good. There are 2 dining areas allowing choice of venue. Tables were set attractively with quality linen, cutlery etc. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 17 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 – 18 Standards relating to complaints and protection were satisfactory. EVIDENCE: There is a complaints procedure on display for visitors in the home and all residents have a copy of the complaints procedure included in the service users guide which is located in their bedrooms. No complaints have been received by the home or the Commission since the last inspection. There is a vulnerable adults procedure in place. It was suggested that all staff are given a copy of this and sign to indicated they have received and understood the document. Abuse issues are discussed at staff meetings and checked as part of the supervision process in relation to policies/procedures. He home are still trying to source a suitable training session relating to Adult Abuse. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 – 26 There is a good standard environment that is well maintained. An extension to the home provides superb additional communal and en-suite bedroom facilities. There has been re-carpeting and redecoration of the ground floor corridor areas and dining area since the last inspection. The call system requires extensions to ensure residents have easy access to the system at all times. Tables to hold drinks, etc. must be provided next to all seats in lounge areas. Standards of cleanliness throughout the home are high. Changes to laundry and bathroom areas to be notified to the Commission when decisions are made. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 19 EVIDENCE: The new extension to the home was completed 6 months ago and now provides 6 additional bedrooms with en-suite facilities. Walk-in shower facility, additional dining area, lounge and conservatory area. The new building is to a high specification with quality furniture, fittings and equipment provided. There are plans to provide a patio and safe garden area at the rear and also to extend the laundry facilities. The new conservatory area is excellent – but sadly, presently unused. This is referred to in Standard 12 above. There is a reluctance on the part of residents to use this area and the heating has been turned off. It is important to further encourage residents to use this area that provides superior facilities provided at great cost and to a very high specification. The area provides views of the garden and patio area, important during the winter months. It was noted that the chairs in the inner small lounge were located around the perimeter of the room and there were no small tables on which to place drinks. The 11am drinks were given to most residents in their hands, which is unsatisfactory and potentially dangerous. Tables must be placed between all chairs to allow a constant supply of drinks directly to residents and in safety. All communal areas and a sample of the bedrooms areas on both floors were seen. All bedrooms have door locks and residents offered keys. The majority of bedrooms have en-suite facilities (only 2 without) and 2 bedrooms are shared but have privacy screens in place. There is an assisted bathing facility on the ground floor and a walk-in shower area in the new build on the first floor. There is an additional (unused) unassisted bathroom on the first floor and the proprietors are considering a rearrangement in this area. Plans will be submitted to the CSCI when final decisions are made. A requirement in the last report to adjust self-closing fire doors to ensure they close properly onto the door recesses has been addressed. A requirement in the last report was to ensure that residents had easy access to the call system. This is not the case. There was no extension to the only call system in the front lounge, the call button being behind the chairs placed around the room. An extension must be provided and the home should carry out a review of all call points to ensure extensions where required are in place. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 20 Bedrooms were well personalised reflecting the individuality and interests of residents. All were comfortable, well furnished and standards of hygiene and cleanliness were high. There were no mal-odours in the home. The laundry was not inspected on this visit and is presently subject to rearrangement/extension by the proprietors. CSCI will be informed when finalised. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 – 30 Staffing numbers have been increased as required for the increase in number of residents. Staff training has been undertaken and further in process or planned. Recruitment procedures ensure the protection of residents. The number of NVQ trained staff meets the recommended level. EVIDENCE: A requirement was made in the last report to increase staffing levels in line with increased occupancy as previously agreed. This has been actioned. The occupancy level has now moved to 20 people and the staffing rota confirms that there are now 3 members of staff on duty throughout the day from 7a.m – 10 pm and waking night care workers from 10pm – 7 am. Additionally the manager works 2.5. days supernumerary to the rota. There are also domestic/catering hours from 9 – 1.30 each day with the exception of weekends when an additional carer is employed for catering purposes. The increased staffing levels are required and adequate for the dependency levels of residents. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 22 Additional funding for a highly dependent resident is included in the above figures, with specific time allocated as required. In the past year 6 staff have completed distance learning course in dementia care. Most staff have received Moving & Handling training. The Manager has recently completed Trainers Course and will now complete updates and training for all staff in this area. Most staff have had training in food hygiene. A course in Adult Protection is being sourced, but staff have access to policy/procedure and discussions in staff meetings and supervision in this area. All staff have had copies of the GSCC Codes of Conduct. The home have reached the target of 50 of NVQ trained staff and funding for placements being secured for Adult Adult Apprentiships for 4 staff over 25 years. All Senior staff administering medication have completed a Medication Administration Course with Wolverhampton College with additional input from local training provider. A date has been arranged for staff training in Infection Control. Staff files relating to recently appointed members of staff were seen. All appropriate references and checks had been secured prior to employment. POVA First checks allowed employment with CRB details to follow. All documents required under Schedule 2 had been obtained. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 23 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, 36 and 38 The 5 standards relating to Management & Adminstration are found to be met. EVIDENCE: The Registered Manager has the required experience to run the home. She is presently studying NVQ4 and hopes to obtain the Registered Managers Award in the near future. She takes a positive lead in the home, spends half her time “hands-on” on the rota and half engaged in management duties. She impresses with a detailed knowledge of residents needs and clearly knowledgeable about the dynamics of the home. She was not previously known to the inspector but demonstrates clear understanding of the needs of residents, staff and visitors promoting an open management atmosphere in the home. She is keen to listen and discuss issues and is receptive to suggestions for service improvement. She has clearly worked hard to achieve good standards. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 24 Regular bi-monthly supervision is provided for all staff and recorded. Records seen were well written, concise and to good professional standards. The Manager is now an approved Moving & Handling Trainer. Fire records were inspected and checks of the alarm system and equipment had been carried out and recorded at required intervals. A fire risk assessment had been completed. The majority of staff have received first aid training sufficient to deploy one trained person on each shift. Risk assessments were in place for resident activity and reviewed on a regular basis. All required incidents under Regulation 37 have been reported to the Commission. The home have an induction programme (seen) which meets required NTO standards. Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 25 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 2 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 x 3 Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Four Seasons DS0000008231.V285827.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 DS0000008231.V285827.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!