Inspection on 16/01/06 for Four Winds Residential Home

This inspection was carried out on 16th January 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 Winds Residential Home 17/11/06

Four Winds Residential Home 29/06/05

Four Winds Residential Home 11/10/04

Four Winds Residential Home 11/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Four Winds Residential Home Elwick Road Hartlepool TS26 0DD Lead Inspector Mr Stephen Ellis Unannounced Inspection 16th January 2006 1:50 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 Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Four Winds Residential Home Address Elwick Road Hartlepool TS26 0DD 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) 01429 869019 Mr Matt Matharu Sally Anne Sharples Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named individual who is in the category (MD) mental disorder is allowed to reside in the home. 29/06/05 Date of last inspection Brief Description of the Service: Four Winds is a care home for older people who require personal care. The home is situated in its own grounds in a residential area close to Ward Jackson park in Hartlepool. The home is a large converted house, which has been extended to give both single bedroom accommodation and double bedrooms for those who choose to share. A passenger lift connects both floors. The home provides lounge and dining facilities for residents’ use. Car parking is available at the front of the building. There is a patio area and landscaped garden to the rear. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours and ten minutes. The inspector looked around the building, examined a number of records and spoke with 9 residents. Comments were also received from 3 staff, including the registered manager. What the service does well: What has improved since the last inspection? There have been no significant changes since the last inspection in June 2005. However, a number of improvements have been made over the past 12 months, including a new bathroom upstairs; installation of a vertical passenger lift; decoration of the new conservatory and landscaping of the rear-garden. Also, a new laundry and separate boiler room are operating on the lower ground floor. High standards of furniture, fixtures and fittings were evident throughout, along with good decoration and carpeting. The home has used questionnaires and a suggestion box as part of its quality assurance checks on its performance. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Prospective residents have most of the information they need to make an informed choice about where they live. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. EVIDENCE: Some key information for residents and prospective residents needs to be updated. The home’s statement of purpose and its service user’s guide need to be amended to reflect the current position. For example, the name of the new registered manager and her qualifications; also, details concerning the registered provider need to be updated. Residents commented that the care home understood their needs well. These included their health and social care needs. They expressed confidence in the staff team in these matters. Detailed assessments of need were evident in residents’ plans of care. The home’s policy and practice ensured that only those service users whose needs could be fully met by the service were admitted. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Service users’ health, personal and social care needs are set out in individual plans of care. Service users’ health care needs are fully met. The home’s policies and procedures for dealing with medicines require amendment so that residents are fully protected. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Residents spoke very positively about the care arrangements at this home. A typical comment was: “It’s so homely, with excellent staff who are kind and attentive; the food is also very good”. Others said: “We’re very happy here”. Residents said they were satisfied with the health and social care provision. They also indicated that they were treated with respect and their right to privacy was upheld. These comments were borne out by the case files and care plans, that were generally well organised, detailed and comprehensive; and by staff comments and staff training (for example, over 80 of care staff members have achieved Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 10 National Vocational Qualifications (NVQ) at level 2 or 3). Staff members clearly enjoyed their work and had a good rapport with residents. However, care plans were being reviewed every 3 months. They should be reviewed at least monthly. Also, risk assessments for pressure sores and use of a portable heater in a bedroom should be documented where appropriate. Provision of sitting scales is desirable: there are some residents who cannot be weighed using standing scales and where careful monitoring of weight is necessary. The home’s arrangements for medicines are sound except for the crucial fact that residents’ medicines are re-dispensed (or ‘put up’) by senior staff some time prior to being administered to residents. Although precautions are taken by the home in the application of this method, it is inherently unsafe and must stop. The home is considering using a monitored dosage system where the dispensing pharmacist supplies the medicines in blister packs or cassettes. The home’s policies and procedures on medicines will need to be amended accordingly. Most care staff members have completed Safe Handling of Medicines training. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. They are able to maintain contact with family, friends, representatives and the local community as they wish. They are helped to exercise choice and control over their lives. Residents receive a wholesome, appealing, balanced diet, in pleasing surroundings at times convenient to them. EVIDENCE: Residents said they enjoyed living at the home. Many commented on the good rapport with staff. As one resident said: “We’re very happy here and get on well together; we’re well fed with very good cooks; we play games when we need the stimulation, such as bingo or spelling games”. Many said the staff members were kind and supportive and used words like “lovely” and “excellent” to describe them. Residents confirmed that they could choose how they spent their time in the home and were free not to join in activities and social events if they did not wish to. All residents described the catering as being good or very good. There was a good choice of menu and residents’ preferences were catered for wherever possible. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 12 A varied programme of social and recreational activities is provided, including regular social events at the home involving residents, relatives and staff. Also, there are occasional outings to places of interest, using a specially adapted bus, hired for the purpose. Two members of care staff take responsibility for leading on social and recreational activities. Recent activities have included a carol service at a local secondary school, plus tea party and presents; a musical entertainment at the Town Hall and a visit to the home from a singer. A mobile library visits monthly and large print books are supplied. One resident enjoys listening to ‘talking books’. Some residents like to sit and chat. Some like to watch TV or listen to music. Some like to play cards and/or bingo. Some residents go out with their relatives or friends, especially when the weather is good. Individual records of social and recreational activities are kept and these confirmed comments received from residents and staff. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Residents are protected from abuse. EVIDENCE: Pre-employment checks are carried out on staff, including enhanced checks with the Criminal Record Bureau and Protection of Vulnerable Adult checks. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. This is to try to ensure that unsuitable people are not employed to care for vulnerable adults. New staff members go through induction and foundation training to ensure they have the right knowledge and skills to do their jobs competently. Most care staff members have completed Protection of Vulnerable Adults training, such as “No Secrets” or via their NVQ programmes. Residents reported a caring, supportive atmosphere in the home, which is well established. There is good leadership and teamwork evident and these features reinforce the caring culture and provider policies concerning adult protection. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic, although paper towels should be installed in wallmounted dispensers in communal toilets. EVIDENCE: There were no unpleasant odours and the home was found to be clean in all the areas inspected. Most care staff members have completed training in Health and Safety, Fire Safety and Food Hygiene. Many have yet to do training in Infection Control, but this is planned for later this year. Paper towels, as well as liquid soap, need to be provided in communal toilets and bathrooms in wallmounted containers, to promote hygienic practices (although residents have personal flannels and towels in their rooms). Residents said that they were pleased with the premises, finding them comfortable and homely as well as practical. They also described the home as being clean. The home is well maintained with repairs and servicing being carried out promptly and according to schedule. However, suitable locks still need to be fitted to bedroom doors in Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 15 the interest of privacy, choice and dignity (the provider intends to carry out this work as soon as the locks and keys have been made to his specification as part of a larger order, in the near future); one en suite toilet on the ground floor needs a call point to be fitted; and a second assisted bathing facility should be provided, ideally on the first floor, to complement the assisted bathroom on the ground floor. The current first floor bathroom does not permit assisted bathing. Provision of a chair hoist should be considered, to promote residents’ choice and safety. Remedial work to the kitchen, including that identified by the Environmental Health Officer, should be completed promptly. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staffing numbers and mix of skills are appropriate for the needs of residents. Care staff members are trained and competent to do their jobs, with over 80 having NVQ level 2 or above. The home’s recruitment policy and practices support and protect residents. EVIDENCE: On the day of inspection, there were 22 residents being accommodated, including one in hospital. Residents said that they got on well with staff and felt that there were sufficient numbers of staff to meet their needs. This view was reflected in staff comments. Staff morale was reported to be good. During the day (7am to 10 pm) there are two care staff members on duty, one of whom is a senior. In addition, between 8 am and 12 noon, and between 4.30 pm and 7.30 pm, a third carer is deployed. At night, there are 2 care staff members on duty, one of whom is designated as being in charge. The manager and/or the deputy are on call at night. The home’s manager is full time, with 40 of her time being dedicated to management duties and 60 to care, when she works ‘on the floor’ providing direct care to residents. In a home of this size, the Commission would expect the registered manager to be completely supernumerary, or at least for the majority of her time to be given over to management duties. Consequently, it is strongly recommended that at least 60 of her time should be dedicated to management duties (when she is supernumerary). Catering and domestic hours are appropriate. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 17 A full staff training and development programme is in operation, including moving and handling, first aid, safe handling of medicines, protection of vulnerable adults, health and safety, fire safety and food hygiene. The manager reported that the home is planning to arrange staff training in infection control and dementia awareness, which are highly desirable. Staff confirmed that they had undergone induction and foundation training. Thirteen out of the 16 members of care staff had achieved qualifications at NVQ level 2 or 3 (81 ), which is commendable. Pre-employment checks are carried out on staff, including enhanced checks with the Criminal Record Bureau and Protection of Vulnerable Adult checks. Also, two references are obtained in respect of each new employee, with special attention given to the last employment. This is to try to ensure that unsuitable people are not employed to care for vulnerable adults. New staff members go through induction and foundation training to ensure they have the right knowledge and skills to do their jobs competently. Most care staff members have completed Protection of Vulnerable Adults training. Residents reported a caring, supportive atmosphere in the home, which is well established. There is good leadership and teamwork evident and these features reinforce the caring culture and provider policies concerning adult protection. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. The manager of the home is fit to be in charge, of good character and able to discharge her responsibilities fully. The home is run in the best interests of residents. Residents’ financial interests are safeguarded in those situations where the home is involved. Staff are appropriately supervised. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The registered manager is becoming increasingly experienced and competent in her new role, having worked at senior and deputy levels for many years. Residents and staff spoke well of her leadership skills and commitment to good outcomes for residents. She was described as being approachable and caring. She intends to register for the Registered Manager’s Award at NVQ level 4 in Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 19 the near future. She also intends to work towards her NVQ qualification in care at level 4, having previously achieved NVQ level 3 in care. Good accounting procedures are followed, with receipts and signatures being provided for all financial transactions involving residents’ personal monies, in which the home is involved, wherever practicable. Relatives look after the personal monies of many residents. In those situations where the home helps look after residents’ monies, such as pocket monies, clear individual accounts and records are maintained. Comments received from staff and management confirmed that there are good health and safety policies and practices that promote the health, safety and welfare of residents and staff. All staff members do refresher training in Health and Safety, such as moving and handling, fire safety and food hygiene. This helps reinforce the registered provider’s written policies on Health and Safety. Health and Safety issues are also discussed at staff meetings. Residents and staff expressed satisfaction with the way the home was run and the good standards that were evident in many instances. They said they believed the home was safe and run in the best interests of residents. For example, there is an annual survey of residents’ satisfaction carried out and the findings are reported within the home. There is, however, a need for the registered provider to report on the findings of his monthly, unannounced visits to the home, in keeping with regulation 26 of the Care Homes Regulations 2001. Copies of the report must be sent to the Commission for Social Care Inspection and the home’s manager. The registered owner, Mr Matharu, visits the home most days and is well known by service users and their families. The manager said that Mr Matharu was supportive and helpful concerning the home’s aims and objectives and in promoting improvements. Formal supervision of care staff takes place at least six times per year and there is an ‘open door’ policy so far as staff consultation is concerned. Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 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 x 17 x 18 3 3 x 3 x x x x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 x 3 3 x 3 Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 21 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. 1 2 3 Standard OP1 OP7 OP7 Regulation 4, 5, 6 15 13 Requirement The home’s statement of purpose and service user’s guide need updating. Care plans need to be reviewed at least monthly (not 3 monthly as at present). The use of a mobile heater in a resident’s bedroom should be subject to a written risk assessment. The practice of ‘putting up’ (or re-dispensing) medicines in advance of their administration must stop. Photographs of each resident should be placed in the Medicines Administration Record, to aid identification. Suitable locks are required to be fitted to bedroom doors. The previous timescale of 01/12/05 was not met. Paper towels should be supplied in communal toilets. All (or at least the majority) of the registered manager’s hours should be supernumerary (that is, not counted towards the direct care hours provided ‘on the floor’). DS0000045233.V260923.R01.S.doc Timescale for action 28/02/06 28/02/06 31/01/06 4 OP9 13 16/01/06 5 OP24 23, 12 30/04/06 6 7 OP26 OP31 13 8 28/02/06 28/02/06 Four Winds Residential Home Version 5.0 Page 22 8 9 OP19 OP33 23 26 Remedial work in the kitchen 28/02/06 must be completed promptly. Reports of monthly regulation 26 28/02/06 visits to the home, carried out by the registered provider, must be sent to the CSCI and registered manager. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP21 OP21 OP8 OP8 OP31 Good Practice Recommendations The first floor bathroom would benefit from being upgraded to permit assisted bathing. One en suite toilet requires a call point to be fitted. A risk assessment tool for pressure sores should be used where residents may be at risk. Sitting scales are desirable because not everyone can use ordinary scales and there are some residents whose weight needs to be closely monitored. The Registered Manager is expected to achieve National Vocational Qualifications (NVQ) at level 4 in management and care within a reasonable time (for example, 12 to 18 months). Four Winds Residential Home DS0000045233.V260923.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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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