Inspection on 13/12/05 for Fourways

This inspection was carried out on 13th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fourways 12/02/09

Fourways 13/02/07

Fourways 29/06/05

Fourways 30/11/04

Fourways 04/05/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Fourways 3 Bramber Avenue Peacehaven East Sussex BN10 8LR Lead Inspector Melanie Freeman Unannounced Inspection 13th December 2005 10:00 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 Fourways DS0000013989.V270008.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. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fourways Address 3 Bramber Avenue Peacehaven East Sussex BN10 8LR 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) 01273-585670 01273-580730 david@4ways.freeserve.co.uk Mrs Pamela Dorothy Darch Mr David Charles Darch Mrs Pamela Dorothy Darch Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21), Physical disability (15), Terminally ill (6) of places Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the maximum number of service users to be accommodated at any one time is twenty one (21). That the care home provides general nursing care to older people aged sixty five (65) or over on admission. Can provide personal care to older people aged sixty five (65) or over on admission to a maximum of nine (9) Can provide care to people aged eighteen (18) or over with a physical disability up to a maximum number of fifteen (15). Can provide care to people aged eighteen (18) or over with a terminal illness up to a maximum number of six (6). 29th June 2005 Date of last inspection Brief Description of the Service: Fourways is registered as a care home providing nursing care and personal care for 21 residents under the categories of old age, physical disability and terminally ill. The home have a special interest in Huntingtons disease and at present have five residents with the illness. Fourways is situated in a quiet residential area on the coast with views over the channel. It provides 19 single rooms and 1 shared room. Bus routes and local shops are nearby. The home has a rear garden with seating and tables. There is also a patio area that is well used by service users. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Fourways Nursing Home will be referred to as ‘residents’. This report should be read in conjunction with the report of the inspection that took place on 29 June 2005 for an overview of the core standards inspected over the year. This was an unannounced inspection carried out on a weekday in December 2005. The homeowner/manager was on duty and was able to contribute to the inspection process along with the deputy managers who received the inspector’s feedback. The inspector spent time with residents and visitors and was able to review the homes progress in meeting the requirements made at the last inspection. Staff were spoken to and observed whilst working. The care documentation for 2 residents were reviewed in depth and the home was toured to review the facilities. What the service does well: What has improved since the last inspection? The home has made good progress towards meeting the requirements made at the last inspection. A clear record of any assessment completed on a prospective resident is now recorded and is included in the care documentation. Systems and procedures for the safe storage and administration of oxygen have now been established. Fourways DS0000013989.V270008.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. Fourways DS0000013989.V270008.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 Fourways DS0000013989.V270008.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): 3 and 4 The admission procedure ensures that there is a full assessment of people prior to their admission to the home and they are assured that their needs can be met in the home. EVIDENCE: The admission procedure includes a full assessment of any prospective resident with input from other health care professionals as necessary. This assessment is now recorded and forms part of the care documentation retained within each resident’s individual’s files. The pre-admission assessment is used to ensure the home has the environment, facilities and staff skills to meet the needs of any proposed resident, and the deputy manager gave examples when residents were not admitted to the home as they needed further medical support. Fourways DS0000013989.V270008.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 and 9 The home was found to be meeting resident’s health and general needs with the support of health care professionals who work closely with the home. Although the administration of medicines in the home was seen to be safe systems need to be fortified to ensure best practice. EVIDENCE: Two individual plans of care were inspected and were found to contain full assessments and comprehensive plans of care. This care documentation was found to be up to date and reflect the health care needs of residents, giving clear guidance to care and nursing staff. Contact with other health care professionals and hospital staff is clearly recorded. Visitors and residents were very complimentary about the care, staff and management of the home. One regular visitor said ’I would not want my friend anywhere else’ and a resident said that ’this is THE place to be’. A registered nurse who takes a professional responsibility for their own practice administers all medicines in the home. During the inspection it was noted that when medicines are not given the reason for this was not recorded accurately. Procedures to underpin best practice need to be provided in respect Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 10 of the use of subcutaneous fluids and the administration of controlled drugs. Following the inspection the inspector discussed the best practice procedures for the safe administration of Controlled drugs with the CSCI pharmacist and she confirmed best practice would include 2 people checking the dose before administration. Fourways DS0000013989.V270008.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): 14 and 15 Resident’s choices and wishes are respected. The provision of meals is well managed and this ensures that the quality of food is good, and that choice and variation is available. EVIDENCE: It is very evident after spending time in the home that Fourways is a home that residents can call their home and that it is run with the individual residents well being taking priority. Resident’s choices are promoted and flexible arrangements in the home allow for this. Entertainment and leisure time is based on family activities and during the inspection staff were busy arranging Christmas festivities that staff residents and visitors were looking forward to. Staffing numbers allow for residents to go out of the home on a daily basis one resident said she enjoyed going shopping and staff helped her with this. The meal eaten by the inspector was found to be well presented and to have a very good taste with an emphasis on home cooking and fresh ingredients. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 12 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 Procedures in the home ensure that any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has relevant guidelines on the protection of vulnerable adults and staff are receiving appropriate training. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 13 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): 19,20,25 and 26 The home provides residents with a comfortable and safe environment that has a home like feel where their needs can be met. EVIDENCE: Fourways nursing home is a converted family home and as such has retained a home like environment that is enjoyed by residents and staff. It is well decorated and has the necessary equipment to meet the specific care needs of residents. A family lounge and dining room is located on the ground floor. These rooms are attractive and well used. Resident’s rooms are very individual, furnished and decorated to meet their tastes and needs with safe heating and water supply. As a converted premises the home has some limitations staff are fully aware of these and keep resident’s needs under review with regular reassessment to ensure their needs can be fully met in the area of the home that they are being accommodated in. The home owner/manager confirmed that the bathing facilities on the first floor are to be upgraded in 2006. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 14 Fourways was found to be very clean on the day of this inspection. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 15 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 Staffing arrangements are good with sufficient numbers of skilled staff employed to meet resident’s needs. EVIDENCE: At the time of this inspection 17 residents were living at Fourways. Residents and a visitor spoken to were very positive about the staff in the home, their comments included; ’the staff are lovely’ ‘staff will do any thing for you’ ‘staff are wonderful’. Staffing levels seen confirmed that they are good and appropriate to meet the specialist care and social needs of residents. Records confirmed that these levels are maintained and that staff turnover is low, and that agency staff are never required. The nursing and care staff are also supported by catering and domestic staff who work closely with them and have regular contact with the residents. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 16 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): 31,33,34 and 35 The home is well managed by the home manager/owner who has the skills and commitment to run the home in an open and positive way that promotes an inclusive atmosphere. Quality assurance monitoring does not record residents/relatives views or levels of satisfaction. Practice in the home does not ensure residents monies and possessions are recorded accurately. EVIDENCE: The registered manager/homeowner and her husband are very involved in running the home and are in the home most days. Relatives were very complimentary about the manager/owner and her management team that works in a very close and consultative way. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 17 The homeowner/manager confirmed that an accountant deals with the homes finances, and the inspector was advised that annual forecasts are generated and available to the CSCI if requested. A quality assurance system based on seeking residents has not been established Some small amounts of money and valuables are kept by the home when requested to by residents or their representatives. Although there is a procedure for this it was confirmed that this was not being followed in respect of accurate records being maintained. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 2 X X X Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 13(2) Regulation Requirement That clear procedures are provided and followed for the administration of controlled drugs, subcutaneous fluids and when medicines are not given. That a full quality assurance system is established and used to maintain and improve the provision of care and services in the home. That the homes policies and procedures are reviewed on an annual basis. That clear procedures to provide safe practice and clear records in respect of residents monies and possessions. That staff are given training on safe moving and handling by a competent person and that the policy and procedure is updated. Timescale for action 01/02/06 2. OP33 24(1) 01/04/06 3 OP35 17(2) 01/02/06 3. OP38 13(2)(5) 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 20 No. 1. 2. Refer to Standard OP1 OP18 Good Practice Recommendations That residents views are included in the service users guide. That the adult protection procedure includes a flow chart with relevant telephone numbers. Fourways DS0000013989.V270008.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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