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Inspection on 15/09/06 for Four Seasons Care Centre

Also see our care home review for Four Seasons Care Centre for more information

This inspection was carried out on 15th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents and relatives were very happy with the care being delivered at Four Season`s and believed they were well cared for and supported by the staff team. They said, " The staff here are so kind, they are always there for you". Another resident said, "They are good to us, they are interested in us, you are not left floundering on your own, there is always somebody to turn to". Relatives said, "The staff are excellent and they look after all of the needs of the patients all the time", "I cannot recommend a better home for mother". Staff members said, "The best thing about Four Season`s is that the residents are well cared for and there is a good rapport with staff members and relatives", "Life for the residents is nice, they get everything they want, I believe they are well cared for and comfortable". The activities and social events for residents are good, with a range of individual and group activities as well as regular outings. The activities are developed with a good knowledge of the resident`s individual social and lifestyle needs as well as care needs. Relatives said, "There are many outings for the residents and activities inside the home". Meals are also well enjoyed by all, with a good range of choice and variety.

What has improved since the last inspection?

Residents care records have improved since the last inspection and they now contain the required information. During discussion and as advised by the proprietor, a number of environmental improvements have been made to Four Season`s, which include new furnishings in a number of areas, upgrading of the shower rooms and an ongoing programme of redecoration to the match the quality and standard of the new unit.

What the care home could do better:

Although improvements have been made to the environment at Four Season`s there continues to be a number of areas that need further redecoration and refurbishment. This includes some of communal areas and bathrooms/toilets and some individual bedrooms. Although the actual recruitment policies and procedures are very detailed and contain the appropriate information and guidance, the actual practise was found to be inadequate and not robust. A number of other records were in need of some updating, such as Statement of Purpose and complaint records. Some review is also needed in respect of health and safety with the need to ensure that the five-year periodic electrical installation is up to date; the staff training records need to clearly demonstrate how up to date the staff team are in regard to their mandatory training.

CARE HOMES FOR OLDER PEOPLE Four Seasons Care Centre Ox Close Saltburn-by-Sea TS12 1NR Lead Inspector Jackie Herring Key Unannounced Inspection 15th September 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 Care Centre DS0000063463.V309905.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 Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Four Seasons Care Centre Address Ox Close Saltburn-by-Sea TS12 1NR 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) 01287 624516 01287 624008 Key Healthcare (Operations) Limited Care Home 53 Category(ies) of Dementia - over 65 years of age (53), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12) Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two of the twelve MD(E) beds can be used for two existing service users between the age of 55 - 64 years until they are no longer required. They will then need to be removed from the registration certificate. The twelve beds MD(E) can be used for the twelve existing service users until they are no longer required . They will then need to be removed from the registration certificate. The existing 29 bedded unit will provide Nursing Care and the new 24 bedded unit will provide Personal Care. 18th November 2005 2. 3. Date of last inspection Brief Description of the Service: Four Seasons Care Centre has been operational as a Care Home since 1989. In April 2005 Key Healthcare Ltd became the Registered Provider. The home operates two separate units, a 29 bedded EMI nursing unit and a 24 bedded EMI residential unit. All rooms are single rooms and the rooms within the EMI residential unit also have ensuite facilities. The residential unit is newly built and was registered in August 2006. The home is situation on the outskirts of Saltburn and within close proximity of local shops, church and public transport. The weekly charge at Four Season’s is £360 - £550 per week. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and was completed by one inspector over three inspection days, a total of 15 inspection hours. As a key inspection, all of the key standards were examined along with some additional standards. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use services, and that it does what the Care Standards regulations say it must. A tour of the home took place, residents records were examined, maintenance and service records were examined, records including accidents, complaints, menus were looked at and a number of residents, staff and the deputy manager were engaged in discussion about life at Four Season’s Care Centre. A number of resident and relative surveys were completed and returned. A meeting also took place with the proprietors following the second day of the inspection to discuss staffing matters and also to give feedback towards the end of the inspection. It was very clear from the discussions that took place that there is a genuine desire and commitment to improve the environment at Four Season’s Care Centre and to also build upon and further develop the home and systems within the home. What the service does well: Residents and relatives were very happy with the care being delivered at Four Season’s and believed they were well cared for and supported by the staff team. They said, “ The staff here are so kind, they are always there for you”. Another resident said, “They are good to us, they are interested in us, you are not left floundering on your own, there is always somebody to turn to”. Relatives said, “The staff are excellent and they look after all of the needs of the patients all the time”, “I cannot recommend a better home for mother”. Staff members said, “The best thing about Four Season’s is that the residents are well cared for and there is a good rapport with staff members and relatives”, “Life for the residents is nice, they get everything they want, I believe they are well cared for and comfortable”. The activities and social events for residents are good, with a range of individual and group activities as well as regular outings. The activities are developed with a good knowledge of the resident’s individual social and lifestyle needs as well as care needs. Relatives said, “There are many outings for the residents and activities inside the home”. Meals are also well enjoyed by all, with a good range of choice and variety. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 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 Care Centre DS0000063463.V309905.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 Care Centre DS0000063463.V309905.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. Resident’s needs are assessed prior to admission to the home, ensuring their needs can be met. EVIDENCE: An examination of resident’s records took place and they contained evidence of pre admission assessments as well as copies of care management assessments. During discussion about the admission process, it was confirmed that it was relatives rather than prospective residents who decided that Four Season’s was the home of choice, this was due to the residents limitations in terms of their decision making due to having short term memory impairment or mental health needs. The Statement of Purpose available within the nursing unit was in need of updating. Four Season’s Care Centre does not currently provide intermediate care. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 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, 10 Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. The home provides a good standard of care to residents and ensures that the health, personal and social care needs are met. Arrangements for dealing with medication are appropriate for the needs of the residents and are managed in a safe manner. EVIDENCE: Three sets of resident’s records were examined during the inspection, two of which were relatively new residents. They contained good detailed information about individual resident’s needs and were supported by a range of risk assessments and care plans. The information flow was very good and they clearly detailed the assessed needs of residents, they were well presented and individual to the needs of the resident. Care plans were well written and there was evidence of monthly evaluation of care. The assessments and care plans covered a range of health and care needs and incorporated physical, psychiatric and social needs. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 10 Care plans examined contained signatures of resident’s family to confirm that they had been involved in drawing up the plan of care. Files examined contained a record of visits carried out by chiropodists, GP’s, opticians and other health care professionals and during the inspection, a GP and district nurse were seen visiting residents. Residents spoken to during the inspection confirmed that they were well cared for and treated with respect and dignity. One resident said, “ The staff here are so kind, they are always there for you”. Another resident said, “They are good to us, they are interested in us, you are not left floundering on your own, there is always somebody to turn to”. Relatives surveys stated, “The staff are excellent and they look after all of the needs of the patients all the time”, “I cannot recommend a better home for mother”. The medication systems were examined in both of the units, which were in order and staff had received appropriate training and were very knowledgeable about the systems in place. Staff spoke with knowledge about the care needs of the residents and about their role as keyworkers. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 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, 15 Quality in this outcome area is Good. This judgement has been made from evidence gathered before and during a visit to this service. Residents are offered the opportunity of participating in a range of leisure and social activities enabling them to lead active and fulfilled lives. Meal provision is good although the dining room is in need of refurbishment. EVIDENCE: An activities co-ordinator is employed at Four Season’s Care Centre and of the staff, residents and relative spoken to during the inspection, they all spoke very highly of the social and recreational activities. Details of a variety of events were observed to be on display around the home, with photographs of residents participating in these events. The activities co-ordinator spoke passionately about their role and it was very evident that they had very good knowledge about individual residents and their particular needs. Group and individual activities were described as well as outings to the pantomime and circus and trips out to other care establishments to join in with social events. The activities co-ordinator has participated in training to assist in developing activities for people with dementia and some of the work currently being completed with the residents is memory boxes, which really give a sense of history which links to residents having a past and are clearly person centred. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 12 It was good to hear that all of the residents have bus passes and that every effort is made to take the residents out of the home as much as possible. One resident said, “There is good entertainment, particularly the Male Voice Choir, I love them coming”. One relative stated, “There are many outings for the residents and activities inside the home”. Daily life within the home was described as very relaxed and flexible for the residents, staff said, “Life for the residents is nice, they get everything they want, I believe they are well cared for and comfortable”, “Life is relaxed for the residents and flexible, they can stay in bed if they want to and they have a good variety of activities and social events”. Another staff member said, “The best thing about Four Season’s is that the residents are well cared for and there is a good rapport with staff members and relatives”. During the inspection, relatives and friends were observed to visit and it was observed that staff had developed good relationships with relatives. A four-week menu was included within the pre inspection questionnaire. Residents and staff were satisfied with the meals. Residents said, “Oh the meals are lovely, especially the scones, it is good home cooking”. Staff said, “The meals are very good and there is sufficient variety in main meals”. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 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): 17, 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during a visit to this service. Whilst the complaints procedure is available, records to support the procedure in the event that a complaint is made were not accessible. The procedure for protection of vulnerable adults was not available and all staff need to receive training to ensure that residents are protected from abuse. EVIDENCE: A copy of the complaints procedure was observed to be on display in the main receptions of the two units. The complaint procedure detailed within the Statement of Purpose is in need of updating as it contained details of staff who are no longer in post and did not include details of the commissioning authorities. It would also benefit including information such as timescales for complaints to be investigated. The complaints records were not available for examination during the inspection and the deputy manager said that there had only been one complaint. It was unclear if this complaint had been fully investigated and whether the complainant was satisfied with the outcome. Residents and relatives said that if they had any concerns they would speak with staff about them. One resident said, “If I had any worries or concerns, I would speak to some-one in charge”. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 14 A procedure for adult protection was not available within the policies and procedure folders, there was however a copy of the Teeswide No Secrets Protocols available within the office. An examination of some of the staff files showed that they had received No Secrets Training. During discussion with some new staff, they had some knowledge of abuse but had not received any training or awareness since being employed at Four Season’s. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 15 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, 20, 21, 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before and during a visit to this service. A number of areas within the nursing unit were in need of attention to enhance the work already completed to ensure a well-maintained and more homely environment for residents. EVIDENCE: Four Season’s Care Centre is a purpose built care home that has recently been extended to create two separate units, a 29 bedded Nursing Unit and a 24 bedded Residential Unit. Since Key Healthcare has owned the home they have commenced a refurbishment and renewal programme, which includes new furnishing, upgrading of the two of the shower rooms, the redecoration of a number of communal rooms and the replacement of some equipment. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 16 During this inspection, a number of areas were identified as in need of improvement within the nursing unit including, the chairs in the smoking room needed to be replaced, as did some of the bedroom furniture, as well as bedroom carpets and corridor carpets. Locks needed to be replaced on nearly all of the toilet, bathroom and shower room doors. Some of the flooring in the bathrooms needs to be replaced and these areas generally needed to be improved to create a more homely, domestic environment. A number of the windows were also in need of attention. The dining room was in need of redecoration and the flooring and seal up to the skirting boards could do with a good clean or replacement. The small bolts on the sluice doors must be removed and the doors locked with a key. A small number of portable radiators were observed in resident’s bedrooms, the inspector was informed that these did comply with the fire authority guidelines and that they had been risk assessed. During discussion, it was identified that there was problems with the heating and that during cold spells a number of areas of the home are cold. The nursing unit did not have the same level of cleanliness as the residential unit and a number of areas were observed to be in need of deep cleaning, this included vacant bedrooms. One of the three washing machines was broken and during discussion it was confirmed that this had been broken for a few months and that as a result it was proving difficult to keep on top of all of the washing. The proprietor did however confirm that a new machine had been ordered and did not think that the current position compromised the laundry situation. The ironing board also needed a new cover. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 17 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, 28, 29, 30 Quality in this outcome area is Poor. This judgement has been made from evidence gathered before and during a visit to this service. The actual skill mix and qualification of staff is not always as required. Staff recruitment practices are not robust and the records do not offer sufficient information to ensure that service users are fully protected. Staff receive induction training and although mandatory training is provided it is unclear how up to date all of the staff team are with this. EVIDENCE: Prior to the inspection it was identified that the home was not being staffed with the appropriate qualification of nurse, that being a Registered Mental Nurse, this continued to be the situation during the inspection through an examination of the duty rota’s and discussion with staff. A recruitment programme has been implemented to hopefully address this issue. During discussions with staff, they said that there were generally sufficient staff on duty to meet the needs of the residents, they did however say that morning time was particular busy as were meals times due to the number of residents who needed help with their meals. A number of staff files were randomly examined and it was identified that a number of staff had commenced employment without a Criminal Records Bureau check and Protection of Vulnerable Adults check. References were not always from the most appropriate person, for example current or present employer. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 18 Staff training records were examined, however they were not up to date and it was not possible to identify in totality whether all staff were up to date with all of their mandatory training. The inspector was informed that there were computerised records however during the inspection process a full picture of the training could not be examined. During discussion following the inspection, it was clarified that not all staff were up to date with the required training however this matter was now being addressed and the outstanding training has now been arranged. There was evidence of additional training opportunities being available, such as, Mental Health, Continuing Care and Epilepsy. One staff member also said they had recently completed a Dementia Care Course at Middlesbrough College, which they found very interesting and informative. Currently sixteen of the twenty-eight care assistants are trained to NVQ Level two or above with three trained to level three and one to level four. During interview with staff, they confirmed they had completed an induction and that they would be progressing on with their NVQ in Care. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is Adequate. This judgement has been made from evidence gathered before and during a visit to this service. Four Season’s Care Centre does not currently have a registered manager. Whilst residents and relative are very satisfied with the home and care provided, a number of systems need to be developed further to enhance the running of the home and to ensure ongoing health, safety and welfare of residents. EVIDENCE: No registered manager in post, the deputy manager has been covering this post for three months and Key Healthcare have now submitted a managers’ application to be processed. Through discussion with the proprietors it was agreed that this appointment was essential as the home was in need of clear leadership. The proprietors clearly take this matter seriously and are in the process of inducting the new manager to ensure they are well versed in the company’s policies, procedures and practices. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 20 Staff supervision records were examined and although some supervision sessions have taken place they were not taking place at the required frequency for all of the staff. The required monthly visits take place as part of the quality assurance system, however in terms of seeking views of residents and their families this was not fully explored on this occasion due to change of management and will be looked at further in the next inspection. This was the same for the system for the management of resident’s personal allowances and finances, although it was confirmed that there were computerised records in place, which are regularly audited. A number of health and safety and maintenance records were examined and in the main, the equipment had been serviced and certificates were in place to demonstrate this. It was identified that the passenger lift had not been serviced, however the deputy manager said this had been completed but there was no certificate in place. The five year periodic testing for the electrical systems was also identified as in need of renewal as was the management of legionella. During a tour of the home, a small number of hot water outlets were too hot, immediate action was taken by the maintenance person to address this. It was however confirmed through discussion with him that the thermostatic mixing valves had not been serviced for some time. It was also identified through and examination of training records, that it was unclear how up to date the whole staff team were in respect of mandatory training. During an examination of the fire records, it was identified that fire drills were not being carried out to ensure that all staff are involved with these drills. Very detailed policies and procedures were made available for examination, a small random sample was looked at and they were found to contain the required information and were supported by corresponding files with the required letters and forms. Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 21 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 2 X 2 3 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N0 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 OP16 Regulation 22 Requirement Timescale for action 30/10/06 2. OP18 3. OP19 The complaints procedure and complaints records must be reviewed and updated and reflect the correct contact details. 13 All staff must receive training in adult protection and the adult protection and abuse policy and procedure must be available within the home. 13, 16, 23 There must be a programme of routine maintenance and a renewals programme, which details dates for completion. Included in this programme must be: • Replacement of a number of carpets. • Redecoration of a number of areas. 30/11/06 31/01/07 4. OP21 23 All bathrooms, shower room and toilet doors must have a working lock and they must be redecorated and more homely and domestic. 30/11/06 Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 23 5. OP24 16 6. 7. OP22 OP26 4,23 6,23,27 8. OP27 18 9. OP29 19 10. OP31 9 11. OP38 13 A number of pieces of bedroom furniture must be replaced, along with a headboard and a number of carpets. Bath seats must have plugs fitted to prevent injury to the resident. The home must be free from any unpleasant odour and must have an adequate cleaning programme along with an adequate amount of working equipment such as washing machines. The appropriate qualification and skill mix of staff must be on duty and available to meet the category of care provided at Four Season’s. The staff files must contain the information as specified in Schedule 2 and procedures must be robust ensuring protection to residents. The proposed manager must fulfil the requirements of the registered manager and complete the necessary process with CSCI. A number of health and safety matters need to be addressed as follows: • All staff must be up to date with mandatory training and records must be in place to demonstrate this. • The five-year periodic electrical test must be up to date, as must the management of legionella. • All staff must be involved in regular fire drills. 31/01/07 30/11/06 30/11/06 31/12/06 30/11/06 31/12/06 31/12/06 Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP1 OP25 Good Practice Recommendations The statement of purpose within the nursing unit needs to be updated to accurately reflect the structure and key individuals of the care centre. The temperature to certain areas of the home should be monitored to ensure they are adequate. The use of portable radiators should be reviewed and where they are considered appropriate, and then risk assessments and confirmation that they meet with the fire service guidance should be included. All staff should receive formal supervision at regular intervals. 3. OP36 Four Seasons Care Centre DS0000063463.V309905.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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