Inspection on 13/02/07 for Fourways

This inspection was carried out on 13th February 2007.

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 13/12/05

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 Key Unannounced Inspection 13th February 2007 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.V326245.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. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 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 585670 4-ways@tiscali.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.V326245.R01.S.doc Version 5.2 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). 13th December 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. They also provide specialist palliative nursing care. Fourways is situated in a quiet residential area on the coast with views over the channel. It provides 19 single rooms and one shared room. Bus routes and local shops are nearby. The home has a rear garden with seating and tables and a patio area at the front of the home that is well used by residents. The home provides care and support to residents who are both privately funded and those who are funded by Social Services and by Primary Care Trusts. The home’s fees as from 01 January 2007 range between £325 for personal care and £420 - £800 per person per week for nursing Care. Additional costs are charged for chiropody (approx £15) hairdressing (£7-8) massage and aromatherapy (£10) newspapers and magazines at cost. Fourways literature states that its aim is to provide a relaxed atmosphere where you will feel safe and secure receiving a high standard of care from the staff, who have time for their individual needs. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 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 was a key inspection that included an unannounced visit to the home and follow up contact with visiting health and social care professionals. This unannounced visit was facilitated by the homeowner/registered manager, the lead nurse and administrator, all of which received the feedback at the end of the inspection visit. The inspector spent time with residents 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. A tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, duty rotas, medication records, and recruitment files. In addition the care documentation pertaining to three residents was reviewed in depth along with a number of policies and procedures and records relating to health and safety. The inspector was able to eat a midday meal with the residents in the communal dining room. Service users surveys were given to ten residents or their representatives and five staff surveys were left in the home for staff to complete and return. The inspector received all ten service users/representatives surveys but none of the staff surveys were returned in time to be included, information contained in the returned surveys has been incorporated into this report. In addition the registered manager/ homeowner completed a pre-inspection questionnaire to inform the inspection process. What the service does well: Fouways Nursing Home provides individual nursing and personal care including palliative care to a high standard within a caring homely environment. All residents and visiting professionals contacted as part of the inspection process confirmed a very high satisfaction with the home, care and staff. Their comments included ‘the care is very good and tailored to be very individual. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 6 The home helps residents to deal with their feelings and emotions’ ‘this is the best nursing home specialising in this care around’. The admission process is comprehensive, ‘person centred’ and conducted in a professional manner ensuring any person admitted can be looked after emotionally and physically in the home. The manager/owner is in the home most days and works closely with the staff residents and relatives, to provide a home and care, tailored to the individual resident’s needs. Fourways Nursing Home is a converted premise that provides a home like environment that is pleasant and attractive. What has improved since the last inspection? What they could do better: Procedures to deal with complaints received need to be established to ensure if any complaint received it is dealt with in a robust and thorough manner. The recruitment practice needs to be further improved with appropriate referencing and a clear record of the identification of each staff member. Staff records also need to include a recent photograph to ensure residents are safeguarded. Hot water accessible to residents must be risk assessed and controlled accordingly to ensure resident safety. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Fourways Nursing Home has the required documentation to provide appropriate information about the home and the services it offers. All residents are assessed prior to an admission being agreed to by a competent person. Residents are only admitted to the home if their needs can be met. Intermediate care is not provided. EVIDENCE: The statement of purpose and service users guide is a combined document and is available in the front entrance area. This has been updated since the last Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 10 inspection and now includes resident’s views on the home and the size of the accommodation provided. It was however noted that the last inspection report was not available within the home at the beginning of the inspection but was located and put with the required documentation. During the inspection visit documentation relating to pre admission assessments was reviewed and confirmed that the admission procedures followed by the home are thorough and includes a full assessment of any prospective resident with input from family, social and health care professionals as necessary. This assessment is recorded and forms part of the care documentation retained within each resident’s individual’s file. Contact with health and social care professionals confirmed a high satisfaction with the admission procedure that was said to be ‘person centred’ and ‘flexible to ensure a responsiveness to individual need’. They also commented on the fact that the home do not admit people that they can not look after and this was taking into account the environment, facilities and staffing of the home and were honest about this from the beginning. As admissions to the home are often completed quickly to respond to the acute needs of people the lead nurse who completes the assessments confirms that the home can meet the needs of the prospective resident verbally. Discussion took place with the management of the home around how the home should record and confirm that it can meet the needs of the prospective resident. It was agreed, as it would be impractical to write to confirm in some cases that the verbal confirmation should be recorded on the admission records and that when admissions are completed over a longer period of time that written confirmation is provided. A review of the homes documentation confirmed that intermediate care is not offered or provided at Fourways Nursing Home. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Individual plans of care set out residents needs and care is delivered in such a way that promotes and protects the residents’ privacy, dignity and independence. Procedures and practice in the home allow for the safe administration of medicines. The emotional and specialist care needs of residents who are dying are very well met. 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. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 12 Not all residents had a photograph within their care documentation and the manager/ owner said that she would ensure that these are retained as previously maintained. Although the documentation reviewed demonstrated regular review discussion with the senior nurses confirmed that a monthly review is not always completed and ways of establishing and recording this in a practical format was discussed and the lead nurse agreed to take this forward. In addition it was noted that residents views on the care documentation is not recorded and again this was discussed along with the need to demonstrate that residents or their representatives are in agreement with the plan of care, clearly this needs to be completed in a sympathetic and sensitive manner. All feedback received was very complimentary about the care, staff and management of the home. It was evident that the home focuses on the individuality of residents and promoting the best health and well-being for each and every resident. Comments received from professionals included ‘this is the best nursing home around and is geared very well towards palliative care. We have been delighted with the standard of care provided to the patients’ ‘We are always confident that any resident sent to the home is very well looked after’ ‘The care is very good and tailored to be very individual’. The records examined and discussions with staff indicated that the home has a very multi-disciplinary approach to the care, advice and support is sought regularly and appropriately. Nutritional assessments are not currently recorded although if nutrition needs are identified these are included in the plan of care. The medicine administration observed was found to be completed in a safe and appropriate manner. All medicines are administered and monitored by the registered nurses working in the home and the storage area was found to provide good facilities for all medicines. Procedures in respect of the administration of controlled drugs, subcutaneous fluids and when medicines are not administered have been provided since the last inspection as required. It was however noted that the medicines records did not include a double signature for the administration of controlled drugs and this is recommended. During the inspection it was noted that residents were treated respectfully and in a caring friendly manner. Resident rooms are very personalised and seen as their own private accommodation. Residents spoken to confirmed that they felt ‘comfortable’ in the home and that they ‘felt like a family member as staff treated them so well’. Fourways Nursing Home provides a high standard of nursing and residential care with a particular skill in specialist palliative care. In order to promote and maintain high standards of care in this area they are working closely with the local Health Authorities in order to implement the Gold Standard Framework and Liverpool Care Pathways in the home. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 13 A resident who had lived in the home for a number of years died recently which affected everyone in the home as he was seen very much as a family member. The funeral started at the home returned there for the reception. This was well attended and helped residents and staff with their grieving process. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Fourways provides and promotes family activity and entertainment that meets the resident’s needs. Contact with visitors and the community is given a high priority along with the promotion of resident’s choices and wishes. 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: Fourways is home to people from different age groups and with different care and nursing needs and this mix provides an extended family feel to the home where the established staff team form close and supportive relationships with the residents and residents care and help each other. Entertainment and leisure time is therefore based on the family activities. Any birthday or seasonal event is celebrated and parties are held regularly in the home and residents said that they enjoyed these. During this inspection it was Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 15 noted that a resident was preparing vegetables for cooking and a valentine day celebration was being organised, one resident said ‘there is always something going on here we never get bored’. Contact with a visiting professional confirmed that Fourways met individual need one recalling that ‘one resident was taken out for rides in the car and on one visit she was found in the garden reading a book under a tree she was very content and able to be her self and the home is flexible enough to allow this’ 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 promote this. The inspector was able to eat a meal with four residents in the communal dining room. This was well presented and had a very good taste with an emphasis on home cooking and fresh ingredients. Residents were able to choose and change what they wanted to eat. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Systems for dealing with any complaint are not clear and robust. Procedures and the management structure in the home ensure that any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The complaints procedure was reviewed and was found not to be adequate and needs to be updated along with appropriate systems to implement a thorough and robust complaints procedure to deal with any complaint that may be raised. The manager/ owner has confirmed that no complaints have been raised with the home and everyone contacted as part of the inspection process confirmed that complaints have not been made. The professionals spoken to were confident that the home would respond positively to any concern raised with them. The home has relevant guidelines on the protection of vulnerable adults and the home has now provided a flow chart, which records relevant contact numbers and the procedure to follow if an allegation or suspicion of abuse is raised. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 17 Two senior registered nurses working in the home have attended Adult Protection training provided by Social Services and are now in process of cascading this training to staff. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 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. As a converted premises the home has some limitations Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 19 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. Since the last inspection three rooms have been provided with en-suite facilities and two have been enlarged. Three rooms remain slightly under 10 square meters and the manager/owner confirmed that the bathing facilities on the first floor are to be upgraded in 2007. Fourways was found to be very clean on the day of this inspection. During the inspection it was however noted that two pots of unlabelled cream were in a communal bathroom, this could pose a cross infection risk and the lead nurse agreed that these would be labelled and stored separately. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staffing arrangements are good with sufficient numbers of skilled staff employed to meet resident’s needs. The homes recruitment procedures followed were found on the whole to be good although improvement is needed with regard to referencing, identification documents and the provision of photographs. EVIDENCE: At the time of this inspection 21 residents were living at Fourways. 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. In addition the registered manager/owner and her husband are in the home a great deal as are the administrator and lead nurse. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 21 All feedback received from residents and visiting professionals confirmed that all staff, the home manager and the lead nurse are very well thought of and comments received included ‘Staff are always very helpful and kind’ ‘The owner is marvellous she puts the residents first as do all the staff’ ‘they all work so hard’. The recruitment files pertaining to the three most recently employed care staff were reviewed as part of the inspection process and identified that the recruitment practice included an application form, referencing and both Protection of Vulnerable Adults and Criminal Records Bureau checks. It was however noted that recent photographs of staff are not retained and one carer’s identification records were not retained in the home. The inspector also noted that some referencing was not thorough and robust for example when references were not supplied alternative references or telephone contact was not followed up. These shortfalls were discussed with the homes administrator confirmed that she would follow up these matters. Staff training is given a high priority and a registetred nurse working in the home co-ordinates all the staff training and has been working on promoting the carers competencies. Last year she completed a course on the safe moving of residents and that has enabled her to train all staff. She has also updated the homes policy and procedure. Staff induction is in depth and thorough however the home needs to ensure that all staff induction is recorded and that they meet the new ‘skills for Care’ induction standards. Although staff training records are held individually on file it is recommended that a staff training matrix is used to confirm the planned and completed staff training and will demonstrate that all mandatory training has been completed. The home manager/owner confirmed in the pre-inspection questionnaire that 52 of staff have achieved a National Vocational Qualification in care level 2. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. 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 measures allow for residents and representatives views to be taken in to account. Systems are in place to ensure resident’s monies and health and safety issues are well managed. EVIDENCE: Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 23 The registered manager/owner 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. Communication at all levels is vital and central to the way the home is run and is well promoted within the home formally during meeting and informally. A visiting professional commented that ‘The home is run very professionally and very patient friendly the patient always comes first’. The systems to monitor the quality in the home have been greatly improved since the last inspection and now focus on resident’s views. Questionnaires have been used to gain individual thoughts and these have been audited identifying areas of quality and areas for improvement that have been responded to. The process and results of this quality review now need to be made available to interested parties and formulated into a report and provided to the CSCI. Some small amounts of money and valuables are kept by the home when requested to by residents or their representatives and procedures followed in respect of this are now clear and thorough and include relevant records including receipts. All records relating to health and safety matters were found to be full and thorough. During the inspection it was however noted that three new basins put into the home have not been fitted with hot water controls and individual risk assessments had not been completed. This was discussed with the homeowner and the lead nurse and she agreed that risk assessments would be completed as a priority. Although a prevention of legionellas procedure is in place action taken in response to this is not recorded and the homeowner agreed to do this in the future. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 24 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 4 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 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 2 Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 25 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 OP16 Regulation 22 Requirement Timescale for action 01/04/07 2. OP29 19(1) 3. OP38 13(4) That the complaints procedure is updated and clearly identifies how the home is going to record and respond to any complaint. That the registered person 01/04/07 operates a thorough recruitment procedure that includes obtaining appropriate references, obtaining up to date photographs and confirmation of identification. That areas where hot water is 01/03/07 accessible to residents is fully risk assessed and controlled to a safe temperature accordingly. 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. Fourways Refer to Standard OP8 OP9 Good Practice Recommendations That a nutritional assessment/ screening is used for each resident. That all controlled drugs administered in the home are DS0000013989.V326245.R01.S.doc Version 5.2 Page 26 3. OP30 checked by two members of staff people and signed for by two members of staff. That a training matrix is used to record all mandatory training in the home. That all induction training is recorded. Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Fourways DS0000013989.V326245.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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