Inspection on 10/12/05 for Four Winds

This inspection was carried out on 10th December 2005.

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

The inspector 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 Winds 20/09/07

Four Winds 18/04/05

Four Winds 10/11/04

Four Winds 29/09/04

Four Winds 08/03/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Four Winds 32A Church Road Brightlingsea Essex CO7 0JF Lead Inspector Pauline Dean Unannounced Inspection 10th December 2005 09:30 Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 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 Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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 Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Four Winds Address 32A Church Road Brightlingsea Essex CO7 0JF 01206 308176 01206 308961 gam@careconsortium.com 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) Community Care Mission 2000 Limited Miss Elizabeth Ikeolumwa El-Schaeddhaei Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 6 persons) 18th April 2005 Date of last inspection Brief Description of the Service: Four Winds is a detached six bedroom bungalow offering care to six adults with learning disabilities. It is situated in a residential area of Brightlingsea, close to shops, post office, G.P. surgery and the seafront. Public transport is available, with the home having their own transport; a people carrier or car. Accommodation is in single rooms, with en-suite wash hand basins and toilets. Shower and bathing facilities are found in the bathroom, with a separate shower room. In addition there is a separate toilet. Staff have a shower room off of the office/staff room. Service users have the use of the dining room and communal lounge. There is a television and music centre in this room. Both the kitchen and separate laundry/utility room are domestic in character. There are gardens at the rear and in the centre of the bungalow. The centre quadrangle is an enclosed patio area, with garden seating and the rear garden is laid to lawn with a paved patio area, fruit trees, flowers and bushes. A summerhouse and garden sheds are used for storage. There is off the road parking at the front of the bungalow. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day on Saturday 10th December 2005. This was the second inspection of the inspection year 2005–2006. Throughout the day there was discussion with Mrs Vasudha Lavangi Gunasene, Director of Community Care Mission 2000 Limited. All six care staff were spoken with during the inspection. The Registered Manager, Miss Elizabeth Ikeolumwa El-Schaeddhael, was not present, but spoke with the inspector on the telephone during and following the inspection. All service users were met during the inspection and they were spoken with during a tour of the premises. Mr David Harden, Director of Finance, came into the home during the inspection to undertake some maintenance tasks and repairs. No visitors or relatives were present during this inspection. Records relating to both service users and staff were sampled and inspected, as were some of the policies and procedures. Seventeen of the forty-three standards were inspected; of these sixteen were met, with one standard nearly met. An anonymous complaint was considered as part of this inspection and this is detailed within the report. There were six elements to this complaint and five were not substantiated, one was partly substantiated. All forty-three standards were inspected over the two inspections of the inspection year 2005–2006, with some standards inspected on both occasions. What the service does well: When asked, Mrs Gunasene said that Four Winds endeavours to focus on the service users. She highlighted “looking after service users well as a priority.” This was evidenced by the detailed individual care planning and risk assessments for each service user that clearly clarifed the care that individuals need and want. Mrs Gunasene said that the home wished for the service users to be settled and happy in their home. Another positive aspect of care at Four Winds had been the reduction in perscribed medication taken by service users. Mrs Gunasene said that the home had sought guidance and consulted with healthcare professionals and had been able to reduce medication intake. As a result the home had seen a marked improvement in behaviours of the service user. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 4 & 5. Clear, detailed information, by the way of the Statement of Purpose and the Service Users’ Guide, is provided to placing authorities, prospective service users and their families to help enable them to make a choice as to whether they wish to be admitted to the home. Prospective service users also have an opportunity to visit and view the home before admission to help enable them to make a choice of whether they wish to be admitted to the home. Service users have individual contracts/statement of terms and conditions, which clarify the services offered. EVIDENCE: Following this inspection copies of the revised and reviewed Statement of Purpose and the Service Users’ Guide were delivered to Commission for Social Care Inspection (CSCI) and these meet requirements. Mrs Gunasene said that prior to admission all prospective service users complete an in depth transition process. At the beginning an initial assessment is completed and short visits to the care home, with their care worker, are arranged. Gradually the length of these visits is extended and overnight stays take place. Mrs Gunasene said that this admission process normally takes two to three months. This was evidenced in the documentation of the most recent admission. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 9 Copies of newly developed service user contracts were brought into the Colchester office of Commission for Social Care Inspection (CSCI). These were found to meet requirements. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 & 9. Service users’ assessed and changing needs and personal goals are detailed in their individual care plans to help ensure that their personal needs are met. Care planning records detail service users’ rights to make decisions about what they wish to do and staff help enable service users to take responsible risks, with both risk assessments and risk management strategies in place. EVIDENCE: Two care plans and risk assessments for service users were sampled and inspected. Reviewed and updated copies of these documents were brought into the Commission for Social Care Inspection (CSCI) and they were found to meet requirements. All aspects of personal care, social support and healthcare needs were considered in these documents. Individual risk assessments and risk management strategies and tools were in place for service users. These were seen on the two files sampled. Detailed reviews and behaviour management strategies were evident and were linked to care planning goals. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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 & 17. Service users’ rights are respected and promoted and their responsibilities are recognised in their daily lives. The home offered a healthy, varied and planned menu, with consideration given to preferences and dietary requirements. EVIDENCE: Throughout this inspection the Inspector observed service users making choices and taking on responsibilities. They were seen to wander freely around the home and they could choose to stay in their room or be in the communal lounge. Two service users acted as the ‘handyman’s helper’ as they assisted the Finance Director with the maintenance and repairs tasks for the day. In the afternoon, four of the service users went to a lunchtime club Christmas party, with two service users choosing not to attend. Four Winds has a four-week rotational menu, with some changes made to reflect seasonal choices. Care staff are involved in the preparation and the clearing away after meals. Nutritional records are kept of food eaten for both the content of the meal and the portions of food served. These records were found to be clearly detailed and were in good order. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 12 One element of the anonymous complaint considered at this inspection was the menu choice. Records showed that service users have a choice of seven types of cereals at breakfast including the porridge, weetabix and cornflakes that were seen in a store cupboard. Staff, records and two service users clarified that they had a choice of cereals at breakfast time. This element of the complaint was not substantiated. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Service users’ personal and healthcare needs are met within the home and records evidenced that service users are supported to access healthcare professionals as needed. The administration of medication for service users was found to be detailed and recorded to help ensure that service users’ health needs are met. EVIDENCE: From sampling care plans it was evident that the home ensures that service users receive personal care and support in the way that they prefer and require. There was evidence of consideration being given to the choice of staff who work with individual service users i.e. same gender. This was noted in care planning records and covered in the staffing rota. Two service users’ files were sampled and inspected. All service users are registered with the local General Practitioners’ surgery and records were seen of input from healthcare professionals, either through visits to the home or to the surgery. In addition, records were seen of visits to consultants and reference to this was found in care planning records and risk management strategies. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 14 Medication storage and administration, and medicines entering and leaving the home were sampled and inspected for three service users. These records were found to be in good order. Records were seen of medication received, administered and leaving the home or disposed of. Currently none of the service user group is taking controlled drugs. Mrs Gunasene said that there has been a reduction in medication held for service users and this was evident from examination of previous Medical Administration Record (MAR) sheets. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Appropriate practices were in place to help ensure that service users’ views are listened to and acted upon and their protection is promoted. Staff training, the awareness of management and staff, policies and procedures and staff recruitment practice promotes this. EVIDENCE: The home’s complaints procedure was seen to be in place and is contained in the Service Users’ Guide. This met requirements. The home has a complaints log for recording complaints, but none had been received by the home since the last inspection. As stated earlier in this report, an anonymous complaint has been received by Commission for Social Care Inspection (CSCI). The elements detailed in this complaint are considered in this report. They were staffing levels, a lack of female care staff, staff working long hours, only foreign care staff employed, registered nurses from abroad only paid a minimum wage and choice of menu with particular regard to breakfast cereals. These elements are covered in this report under the relevant National Minimum Standards. The Adult Protection Procedure and Whistle Blowing Procedure were inspected and were found to meet requirements. Reference is made to local authority guidance and the appropriate Protection of Vulnerable Adults (POVA) referral forms are readily available. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24. Overall, the premises were clean, comfortable, well maintained and safe. EVIDENCE: A tour of the premises was conducted. Overall, the premises were well maintained and on the day of the inspection some maintenance work was in progress. Mrs Gunasene said that a new hall carpet was to be fitted in the coming week and new floor coverings are to be fitted in two service users’ rooms in the immediate future. In addition to the ongoing repair work, a new lounge sofa, a wardrobe and replacement curtain fixings are to be installed in the coming weeks. A planned maintenance programme and record of completed work was seen on the day of inspection. Maintenance work identified at the last inspection has been completed, namely a broken bath panel, a damaged bed and lounge seating have been repaired or replaced. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 33. Service users are supported by competent and qualified staff, with staffing levels and skills appropriate to the needs of service users. EVIDENCE: Mrs Gunasene said that approximately 80 of care staff at Four Winds have achieved a National Vocational Qualification (NVQ) Level 2 in care. In addition, there was evidence of further ongoing basic training courses e.g. Health & Safety, Food Hygiene, Fire Safety, Manual Handling and Protection of Vulnerable Adults (POVA) workshop attendance. In addition, certificates were seen on staff files that evidenced training in Rectal Diazepam procedures, Bowel Management Awareness, Mental Health Awareness, Epilepsy Awareness, Food Safety and Medication training. A planned training course in Physical Intervention was also offered as a refresher course to staff. From reviewing staff rotas, there was evidence that staffing levels were met. Records showed either six care staff and the Manager or five care staff and the Manager on duty. Rotas from the 31st October 2005 to the current rota were inspected and these evidenced this. One shortfall noted was the need to clearly detail on the staff rotas the Manager’s working hours, normally 09:00 to 17:30 on weekdays. On call hours for Mr Gunasene, who covers weekends, also need to be recorded. From the records seen and discussion with Mrs Gunasene, this element of the complaint was not substantiated. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 18 A further concern raised was with regard to the lack of female care staff to care for the one female service user. This too was found not to be substantiated as either the Registered Manager or female staff were detailed as being on duty throughout the daytime and at night. Staff recruitment records, as detailed in the National Minimum Standards – Standard 34, were considered. Whilst this Standard was not considered in full, records were seen of staff recruited from the local area. These were new staff from the Brightlingsea area who were detailed as of British nationality. Mrs Gunasene acknowledged that within Four Winds there was a high percentage of care staff from different ethnic and cultural backgrounds, with some working part-time as they complete their studies. She said, however, this was because of poor performance of other prospective carers at interview and not because of their racial origins. Staff contracts were sampled. None of the care workers at the home are employed in the role of a registered nurse and therefore staff wages do not need to reflect this. This element of the complaint was not substantiated. Staffing rotas were sampled and inspected at this inspection and records, detailing the number of staffing hours for care workers, were requested. Twelve staff were listed as working over the Working Times Regulations 1998 limit of 48 hours per week. From sampling staff records, ‘Opt-out’ Agreements were seen in place. The Registered Provider needs, however, to reconsider the practice of employing staff for long days, some were seen to be working between 49 to 168 hours over a two week period. The home must look to the guidance regarding record keeping for this regulation and closely monitor staff working these excessive hours to make sure that they do not work too many hours. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39. Staff and service users are well supported by the home’s Manager, who is hands-on and part of the care team of the home. An effective quality assurance and quality monitoring system is still required to help ensure that service users’ views are taken into account when monitoring, reviewing and developing the service. EVIDENCE: Mrs Gunasene said that the Registered Manager is currently working on the National Vocational Qualification (NVQ) Level 4 in care and management and hopes to complete this by 2006. Within a staff contract there was a clear job description, which detailed the roles and responsibilities of the Registered Manager. Quality Assurance questionnaires have been distributed and returned. Relatives and advocates completed them. These have been reviewed and details of the outcomes are summarised in an appendix in the revised Service Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 20 Users’ Guide. Some suggestions received from these surveys have been considered and acted upon, with reference made to flexible boundaries and risk assessments and risk management strategies in place. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 X X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 2 X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Four Winds Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000017821.V271681.R01.S.doc Version 5.0 Page 22 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. 1 Refer to Standard YA33 Good Practice Recommendations The registered person should review and monitor current staffing arrangements with regard to the Working Times Regulations 1998 and working over the 48-hour limit. Four Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Winds DS0000017821.V271681.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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