Inspection on 25/07/05 for Three Gables

This inspection was carried out on 25th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Three Gables 20/03/07

Three Gables 04/01/06

Three Gables 14/02/05

Three Gables 26/08/04

Similar services:

1 Marten Road

Daubeney House

Aldwick House

49 Glendale

The Springs Community

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

CARE HOMES FOR OLDER PEOPLE Three Gables Brand Road Eastbourne East Sussex BN22 9PK Lead Inspector Lucy Green Announced 25 July 2005 9:20 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. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Three Gables Address Brand Road Eastbourne East Sussex BN22 9PK 01323 501883 01323 501883 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) Mrs Jennifer Shirley Miss Caroline Shirley Miss Caroline Shirley Care Home 19 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (MD(E)) 19 of places Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is nineteen (19). 2. Service users should be 65 years and over on admission. Date of last inspection 14 February 2005 Brief Description of the Service: Three Gables is a large, detached, three storey property situated in a quiet residential area of Hampden Park. The location of the home is within walking distance of local shops, health services and public transport links. Resident accommodation is provided in single bedrooms, many of which have ensuite facilities. Bathroom and toliets provide assisted facilities. The home has a range of communal areas, including a dining room and two lounges, one of which has an extended sun room. The external grounds offer attractive front and rear gardens. A passenger lift provides level access to the first floor of the home. One bedroom is located on the second floor and the resident who occupies this room, must be able to manage the stairs from the first floor independently. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 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 Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Three Gables will be referred to as ‘residents’. This announced inspection took place over eight hours on 25 July 2005. This is the first statutory inspection of this year. The purpose of this inspection was to assess compliance with the requirements of the last inspection and to generally monitor care practices. A tour of the premises took place, rotas and care records were inspected. Eleven of the seventeen residents, two visitors, five staff and the two Owners were spoken with. Comment cards were left for visitors and a letter and five comment cards had been received at the time of writing this report. The Inspector joined the staff in the dining room for their lunchtime meal. What the service does well: Three Gables is an established home which has been recognised as providing a good quality of service for a number of years. The home is family owned and managed and the Owners are supported by a stable and committed team of staff. Both Owners, one of whom is the Registered Manager have undertaken a wealth of relevant training. The home has good links with a range of healthcare professionals who also speak highly about the care at Three Gables. On the day of the inspection, the Inspector met with a visiting Community Psychiatric Nurse who referred to the standard of specialist care at the home as “exceptional”. The Inspector received positive feedback from relatives, one of whom stated that their relative had made such massive improvements since moving into the home, that it was “a huge relief”. In a letter received by the Inspector, one visitor stated; “I have to express my heartfelt thanks for the tender care given to my relative”. Three Gables provides a wide range of activities for residents to engage in. On the day of the inspection, a craft workshop and singing performance were offering entertainment to the residents. Mealtimes were observed to be a relaxed and friendly occasion. The Inspector sampled the lunchtime meal which was appetising and well presented. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 6 The home is situated in an attractive location and offers a homely environment for residents to live in. Bedrooms are personalised to individual tastes and residents are encouraged to bring their own furniture into the home. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 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 Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 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) 3 & 5 Residents benefit from an admission process which enables all parties to determine whether Three Gables can meet the needs of the prospective resident. EVIDENCE: The assessment information for three residents was viewed. There was documentary evidence that the home had carried out a written assessment prior to admission. The assessment form covers the areas identified in the National Minimum Standards. It was noted that the home had not always a received a copy of the Social Care Assessment and it is required that the home request a copy for all residents who are funded by Social Services. Residents are encouraged and supported to visit the home prior to admission. Prospective residents on occasion have visited Three Gables and had a drink or a meal with the other residents prior to moving in. It is recognised that individual circumstances may dictate that it is either not possible or would be inappropriate for a resident to visit prior to moving. Where this is the case, resident representatives usually visit the home on their behalf. The Inspector Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 9 spoke with one relative, who confirmed that he had visited the home and met with the owners and staff prior to their relative moving in. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 10 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 & 10 Residents benefit from a plan of care that outlines how their health and welfare needs are to be met. Residents would be further protected by the systems in place for managing medication if staff were more diligent in the recording of medication they administer. EVIDENCE: Five care plans were examined and discussed with the Manager. There was evidence that each resident has a plan of care which provides detailed information about their health and welfare needs. The care plans were well maintained and easy to use. One of the owners, reviews care plans on a monthly basis and any changes are recorded. Care plans contain risk assessments for a range of areas, however, it was noted that they did not determine the individual level of risk with controls in place. It is therefore required that the system for risk assessing is reviewed and this additional information included. Care plans were found to contain a record of the input received from other healthcare professionals and copies of letters requesting referrals. On the day of inspection a Community Psychiatric Nurse visited two of the residents. The Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 11 Inspector met with this person, who spoke positively about her experience of the home. She stated that the care provided at Three Gables is “specialist and the standard is exceptional”. She went on to say that the Providers are experienced in this field and that she has never had any concerns about the home. Ten residents were spoken with and the consensus was that staff provided their care with dignity and respect. One relative met with the Inspector and said that his mother “had come back to life” since moving to Three Gables. A letter received by the Inspector from one resident representative stated that she wished to express thanks for the “tender care” given to her friend during the time she lived at the home. The systems for managing medication were inspected. The Manager confirmed that only staff who had received relevant training handled medication and there were certificates in place to reflect this. The storage of medication was found to be satisfactory. It was however, noted that there were a number of inconsistencies between the medication in the blister packs and the recordings on the Medication Administration Record (MAR Sheet). An Immediate Requirement was therefore left for the Registered Person to ensure that staff accurately record whether medication was administered. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 12 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) 12, 13 & 15 Residents are supported to lead healthy and fulfilling lives. Residents benefit from a range of varied and wholesome meals. EVIDENCE: The home provides a range of fulfilling activities for residents to participate in. On the morning of the inspection, an external person had come into the home to hold a craft workshop with a number of the residents. This activity is held every three weeks. Residents were observed engaging in and enjoying this activity. During the afternoon, one of the carers, who was off duty sang to the residents which was proved a popular event. The Manager reported that other regular activities in the home included; Music in Care Homes visiting monthly, a music for health workshop, reminiscence sessions and musical bingos. From the beginning of August the home will also be employing the services of an agency who will provide activities both inside and outside the home three afternoons each week. Three Gables has strong links with local religious leaders and residents are able to attend Communion and other services within the home. The home operates an open door policy for visitors and this was observed to be the case during the inspection. The comment cards and feedback received Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 13 from representatives confirmed that they were also made to feel welcome at the home. One relative informed the Inspector that he always felt welcome at Three Gables and that he is always offered refreshments during his visits. Meals are prepared according to a four-week rotating menu. The menu was seen to be varied and well-balanced. The Inspector joined staff for their lunchtime meal. A choice of two meals was offered and staff and residents confirmed this is always the case. Residents and visitors informed the Inspector that meals are plentiful and appetising at Three Gables. A letter from one visitor stated; “the meals are wonderful, I can testify to that!”. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 14 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) 18 Three Gables has systems in place to ensure residents are protected from abuse. EVIDENCE: Recruitment procedures ensure that staff are only employed at Three Gables following receipt of satisfactory checks and references. The home has an adult protection policy in place which outlines what constitutes abuse and the action that would need to be taken if anyone in the home was alerted to an abusive situation. It is required that the policy is expanded to include information about the Protection of Vulnerable Adults register and the circumstances when people may be referred to this list. This policy should also be cross-referenced with the home’s disciplinary policy. The person responsible for training at Three Gables is booked onto an adult protection training course which will enable her to cascade this training to other staff at Three Gables. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 15 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 & 26 Residents benefit from a clean and homely environment. EVIDENCE: Three Gables is an attractive three storey property situated in a quiet residential area of Hampden Park. A passenger lift provides level access to the first floor of the home. One bedroom is located on the second floor and the resident who occupies this room, must be able to manage the stairs from the first floor independently. Resident accommodation is provided in single bedrooms, many of which have ensuite facilities. Bedrooms were found to have been personalised to the individual occupying them and may residents had brought in their own furniture. Bathroom and toliets provide assisted facilities. One of the upstairs bathrooms is in need of redecoration. The owners informed the Inspector that this bathroom is going to be converted into a walk-in shower room at some future Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 16 point. It is recommended that the home consider redecorating this room if the upgrade does not feature on the maintenance plan for this year. The home has a range of communal areas, including a dining room and two lounges, one of which has an extended sun room. The external grounds offer attractive front and rear gardens. All areas of the home were found to be clean and free from offensive odours on the day of the inspection. The vistors who spoke with the Inspector confirmed that Three Gables is always a clean and pleasant environment to come into. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 17 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, 28, 29 & 30 Residents benefit from being supported by a stable and committed team of staff. EVIDENCE: Discussion with the Owners and examination of the rota showed that staffing levels provide a minimum of: three care staff in the morning, two care staff in the evening and one waking night duty, with one of the Owners sleeping-in at night. During weekdays the Owners’ hours are supernumerary to the rota. In addition to care staff, the home employs sufficient catering and domestic staff to maintain the running of the home. During the inspection, it was observed that there were sufficient staff on duty to meet the needs of the residents. Staff confirmed that current staffing levels provided them with enough time to do their job. There was a consensus from the feedback received from residents and visitors that staff were caring and supportive to them. One resident stated that the staff at Three Gables were “nice, caring people”. All new staff complete an induction and foundation training programme which is in line with the TOPSS specification. Staff confirmed that they have also received other mandatory training. Three care staff have completed National Vocational Qualifications (NVQ) and a two other staff are currently working towards these qualifications. The Owners expressed that they expected to reach the 50 target for NVQ’s by the deadline of 31 December 2005. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 18 The recruitment files for two most recently employed staff were inspected. With the exception of a recent photo for each member of staff, these files contained the required level of documentation. Staff confirmed that they had received a copy of the Code of Conduct laid down by the General Social Care Council and were clear as to their role. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 19 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) 36 & 38 Staff would benefit from the introduction of a formal system of supervision. Systems are in place to maintain the health and safety of Three Gables. Residents would be further protected when the identified issues relating to health and safety are addressed. EVIDENCE: The management of Three Gables allows a lot of time for staff to reflect and discuss their practices. Staff eat a lunchtime meal together each day and a thorough handover is undertaken at this time. Staff expressed that they used this time to raise ideas and ask questions. In addition, monthly meetings are held which are used as training and update sessions. Minutes from these meetings were seen. At the current time, staff do not however, receive regular 1-1 support sessions from their line Manager. It is required that this system be introduced and records of these discussions maintained. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 20 The home has a raft of policies and procedures in place, which staff are introduced to as part of their induction. It was noted that the disciplinary policy should be updated to make reference to the Protection of Vulnerable Adults (POVA) and that the home must report any event which adversely affects the well-being of a resident to the Commission for Social Care Inspection. A senior member of staff is delegated the responsibility of overseeing the health and safety systems for Three Gables. The Inspector met with this person and examined the various logs and audits which she maintains. This person is supernumerary on the rota one morning each week in order to carry out these checks. During the inspection, a few areas of health and safety were identified. As such, it is a requirement of this inspection that staff receive fire training, at least twice each year, by a person ‘competent’ to provide such training. It was also noted that one first floor window was not restricted and it is required that this is addressed. In line with latest requirements from the Fire Brigade, fire doors must not be propped open with door wedges and these items must be removed immediately. Risk assessments for each room of the home should be carried out in respect of fire and health and safety. Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 21 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 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 x 15 4 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 2 x x x x x x 2 x 2 Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 Page 22 NO 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 3 Regulation 14(1) Requirement The home to obtain copies of the Social Care Assessment for all service users funded by Social Services. Comprehensive risk assessments are to be carried out in respect of all areas of residents lives and the controls in place evaluated. Medication to be appropriately adminsitered and recorded for at all times. Policies and Procedures to reflect current guidance on the Protection of Vulnerable Adults. All staff files to contain a recent photograph of the staff member. The home to report any event which adversely affects the wellbeing or safety of any service user to the CSCI. Fire doors to be kept closed at all times, unless fitted with an approved fire safety device. Staff to receive fire training at least twice each year, by a person competent to provide such training. Risk assessments to be carried Timescale for action 10 September 2005 01 October 2005 2. 7 13(4) 3. 4. 5. 9 18 29 13(2) 4 & 13(6) 19 & Schedule 2 (as amended) 37 25 July 2005 01 October 2005 01 October 2005 25 July 2005 25 July 2005 01 October 2005 01 October Page 23 6. 36 7. 8. 38 38 23(4) 23(4) 9. 38 13(4) Three Gables H59-H10 S21271 Three Gables V228079 250705 Stage 4.doc Version 1.30 out on each room of the home in respect of fire and health and safety. The unrestricted window on the first floor to be restricted. & 10 September respectivel y 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. Refer to Standard 19 36 Good Practice Recommendations The small upstairs bathroom to be re-decorated. Staff to recorded supervision sessions at least six times each year. 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