Inspection on 10/08/05 for WCS - Four Ways

This inspection was carried out on 10th August 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

WCS - Four Ways 05/03/07

WCS - Four Ways 08/03/06

WCS - Four Ways 15/02/05

WCS - Four Ways 04/08/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE WCS Four Ways Mason Avenue Lillington Leamington Spa CV32 7PE Lead Inspector Louise Thompson Unannounced 10 August 2005 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 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. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service WCS Four Ways Address Mason Avenue Lillington Leamington Spa Warwickshire CV32 7PE 01926 421309 01926 882034 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Warwickshire Care Services Limited CRH Care Home 44 Category(ies) of OP Old age (44) registration, with number of places WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15 February 2005 Brief Description of the Service: Four Ways is managed by Warwickshire Care Services who have managed the home since it transferred, along with a number of other homes providing care, from Warwickshire County Council in 1992. Warwickshire Care Services are a voluntary sector organization.Four Ways is registered as a care home providing personal care to older people, including two beds, which are used for respite/short stay. Accommodation is over three floors, there is a lounge/dining area upon each floor. 18 bedrooms have en suite facilities. In addition Four Ways caters for up to eight-day care users Tuesday to Friday inclusive. The home is situated in Lillington, which is just outside of Leamington Spa. A regular bus service into Leamington stops nearby. Local amenities such as shops are also located close by. Car parking is provided to the front and side of the building. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over two visits. This was the first visit for this inspection year. Staff co operated fully with the inspection. The registered manager was present throughout the inspection. The inspection process involved a tour of the home, talking with the manager, examining records and care plans, observation of care practices along with discussions with residents, staff and relatives visiting on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Care plans need reviewing to ensure that they are up to date so that the staff are able to know what to do for each resident and ensure that individuals care needs are met. The recording of medicines needs further improvement to minimise the risk of errors in the administration of medicines. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 6 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. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 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 standard(s) These standards were not assessed at this inspection. EVIDENCE: The manager provided the Commission with a copy of the revised Statement of Purpose and Service User Guide. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 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 standard(s) 7, 8 , 9 and 10 Minor changes to care plans are needed to provide the staff with the necessary information to meet individual residents needs. Health needs of residents are met with evidence of liaison with health and social care professionals on a regular basis. The shortfalls in the medication administration records potentially leave the residents at risk. Personal support is offered in such a way as to maintain residents’ privacy and dignity. EVIDENCE: The home has recently introduced a comprehensive new care planning and quality management system. The records of four residents were observed during this inspection. The quality of the assessment and care plans was generally good however some areas of assessment and care planning were incomplete. The manager had recently completed an audit of care plans and had identified areas for action. Good risk assessments were observed with ongoing monthly review of these, which enable staff to monitor changing dependency levels. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 10 Care documentation requires a quality questionnaire to be completed monthly along with a review of care plans. Staff had not recorded care plan changes on this document. The current format does not require care plans to be dated it was not possible to identify and track fully these monthly reviews. Staff were enthusiastic about the new documentation and said they were finding it easier the more they did. The manager and care manager said that information from each of the residents assessments etc were discussed in unit meetings monthly with staff members and had improved communications with regards to residents care needs. Access is available to health professionals outside of the home, which includes the chiropodist, GP, district nurses and the dentist. Care files viewed showed involvement of members of the multidisciplinary team in assessing and meeting residents’ care needs. Systems for the management and administration of medications were observed and were satisfactory apart from the following issues, which were discussed with the manager. • • • Not all medications prescribed as required (prn) clearly specified the reason for administration. Eye drops for one resident specified to be given as directed with no further information and were not dated when opened. MAR sheets transcribed by hand were not always dated. Throughout the inspection it was observed that staff knock on residents’ doors, offer choices and ensure that all personal care and consultations are conducted in private, this assists in maintaining the residents privacy and dignity. Residents told the inspector that they were very well cared for and that staff were very kind and helpful. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 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 standard(s) 15 Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. EVIDENCE: The inspector ate lunch with the residents. The meal was tasty and nicely presented. The dining room tables were attractively laid and staff were readily available to assist residents where necessary. Residents said that the meals were very good and suitable choices were available at mealtimes. Each floor has a small kitchenette and drinks and snacks are readily available. Comments recorded by relatives and residents in the homes’ register frequently complimented the home on the quality of the meals provided. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 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 standard(s) These standards were not assessed at this inspection. EVIDENCE: WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 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 standard(s) 19 and 26 The standard of décor and furnishings provided as part of the recent refurbishment are high. The home presents as comfortable and homely for residents. EVIDENCE: Residents told the inspector that they were very pleased with the refurbishment of the home. Several residents showed the inspector their rooms and said that they had been consulted about their choice of décor . One resident had chosen her wallpaper and a further resident was going to town with staff to choose which wallpaper she wanted her room decorating in. The home was clean and tidy at the time of the visit and there were no odours. Bathrooms and shower rooms contained personal toiletries and sponges, non of which were labelled as belonging to individual residents this could potentially place residents at risk of cross infection. This was dealt with at the time of the visit. Chemicals stored within the laundry were observed to be labelled as WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 14 corrosive an appropraite COSHH risk assessment was in the office but suitable protective equipment was not available. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The number and skill mix of the staff is sufficient to meet the needs of the residents. Staff appear committed and have personal qualities that are important to the residents. The procedures for the recruitment of staff need review to ensure the protection of the residents. Training is well planned and organised and good opportunities are available for all staff. EVIDENCE: Duty rotas seen for the period of a month demonstrate that staffing is maintained within previously agreed levels. Care staff are responsible for the laundry and are assisting with some of the catering duties as one staff member is on maternity leave. Staff do additional shifts to cover for sickness and annual leave. The manager said that she regularly monitors the number of hours staff work. Staff and residents told the inspector that the staffing levels were suitable to meet current care needs of residents. The inspector examined the records of two recently appointed staff members and the file of a staff member recently transferred from another home within the group. Each file contained evidence of CRB checks, references and other information as required by this standard. A management checklist on the front of each file evidenced that staff had been given copies of the General Social Care Council Code of Conduct. Issues with respect to one of the CRB checks WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 16 and the transfer of staff were discussed with the manager and Director of Care at the time of the inspection. The inspector observed the training plan and matrix of training attended by staff members at Fourways. Comprehensive records were maintained and demonstrated good opportunities are available to staff. The manager and staff are commended for their enthusiasm and commitment towards staff development. Induction records were observed for three of the new staff. The manager said that the majority of staff are currently undertaking a distance learning course on Dementia Care which is almost complete. The organisation has achieved Investors In People Award. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36 The quality assurance systems in place ensure that the home is run in the best interests of the residents. Staff are appropriately supervised to ensure that they have the support, skills, practices and knowledge to meet all of the residents needs. EVIDENCE: A comprehensive quality management system linked to resident assessment and care planning has recently been implemented. A management matrix is completed monthly, which enables the homes manager and senior managers to monitor aspects of care and staffing throughout the home. This includes dependency levels and staffing, accident/incidents and complaints. Residents are asked one quality question each month and the responses are recorded. Throughout the year this will give an overall indication on residents views of the home. Resident meetings are held regularly with records of this seen at inspection. In addition to this there is a compliments/complaints book WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 18 on each floor. Policies are produced corporately and are currently under review. Observation of records and discussion with staff demonstrates that staff are receiving supervision with a yearly plan to achieve a minimum of six per year for care staff. WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 3 x x 3 x x WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? 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 OP8 Regulation 15 Requirement The registered manager must ensure that assessments and care plans are specific to each residents, health, personal and social care needs and are up to date.(Old timescale of 31.03.05 almost met) The registered manager shall make arrangments for the safe handling and recording of medication.(old timescale of 28.02.05 almost met) The registered person shall make suitable arrangements to prevent infection and the spread of infection. The registered person must make arrangments for the safe use and storage of hazardous substances. Suitable protective clothing and equipment must be provided. The registered person shall not employ a person without first obtaining confirmation of suitability and other statutory information and documentation as required by the Care Home Regulations 2001. The registered provider shall ensure that a representative Timescale for action 30.11.05 2. OP9 13 31.10.05 3. OP26 13 31.10.05 4. OP26 13 31.08.05 5. OP29 19 Sch 2 31.08.05 6. OP37 26, 17 Sch 4 30.09.05 Page 21 WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 from the organisation visits on a monthly basis and prepares a written report on the conduct of the care home.(old timescale of 30.04.05 not met) 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 OP7 Good Practice Recommendations The inspector recommends that care plans are dated and signed by the staff members responsible and whenever there are any changes to these. Entries should not be made in pencil and correction fluid should not be used. The inspector recommends that the manager obtain a copy of the recently revised induction standards and check that the homes current induction package meets these. 2. OP30 WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 WCS Four Ways E53 S4265 WCS Four Ways V242991 100805 Stage 4.doc Version 1.40 Page 23 - 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. 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