Inspection on 04/01/06 for Three Gables

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Three Gables 20/03/07

Three Gables 25/07/05

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 9PX Lead Inspector Lucy Green Unannounced Inspection 4th January 2006 11:00 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 Three Gables DS0000021271.V263193.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. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Three Gables Address Brand Road Eastbourne East Sussex BN22 9PX 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) 01323 501883 01323 501883 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 (19) of places Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is nineteen (19). Service users should be 65 years and over on admission. Date of last inspection 25th July 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 DS0000021271.V263193.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 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 have requested to be referred to as ‘residents’. This unannounced inspection took place over six hours on 04 January 2006. This is the second inspection of this year and therefore this report should be read in conjunction with the report from the announced inspection carried out on 25 July 2005. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. A tour of the premises took place, medication, health and safety and care records were inspected. Seven of the nineteen residents, two visitors, seven staff and the two Owners were spoken with. The Inspector joined the staff in the dining room for their lunchtime meal and observed an afternoon activity session taking place. What the service does well: What has improved since the last inspection? Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 6 The home has undertaken a lot of work improving health and safety within the home. All windows above ground floor are now restricted and those doors previously found propped open have been fitted with appropriate ‘hold-open’ devices. Staff training has developed since the last inspection with recent training in fire safety, manual handling, continence management and control of substances hazardous to health (COSHH). Staff also reported that they receive regular recorded supervision sessions. The information in care plans, personnel records and policies and procedures has also been updated and improved. 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 DS0000021271.V263193.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 Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 2 (Standard 6 not applicable) Residents benefit from accessible information that outlines the services provided by the home and the rights and responsibilities attached to a placement at Three Gables. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place and the Manager confirmed that copies are made available to both current and prospective residents. These documents provide accessible information about the services offered at Three Gables. A written contract is in place which outlines the terms and conditions attached to a placement at Three Gables. Each resident has been given a copy of the contract and a signed copy is also retained by the home. Three Gables DS0000021271.V263193.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&9 Residents are protected by the documentation in place to support them. 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: Three care plans were examined and discussed with the Owners. There was evidence that each resident has a plan of care that provides detailed information about their health and welfare needs. Care plans are compiled with a multi-disciplinary approach and where restrictions on freedom are necessary, these plans have been endorsed by relevant healthcare professionals. The care plans continue to be well maintained and easy to use. One of the owners, reviews care plans on a monthly basis and any changes made are recorded. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 10 Care plans contain risk assessments for a range of areas and in line with a requirement form the last inspection these have been reviewed and additional information included. The systems for managing medication were inspected. The Manager confirmed that only staff who had received relevant training handled medication. 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 Manager to ensure that staff accurately record whether medication was administered. The home is also required to review the way controlled medication is stored, dispensed and administered. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14 Residents are supported to lead their lives how they choose. Residents benefit from a sociable and inclusive environment where there are lots of opportunities to participate in fulfilling activities. EVIDENCE: The home provides a range of fulfilling activities for residents to participate in. On the afternoon of the inspection, two external activity organisers had come into the home to hold music and exercise sessions with the residents. The Inspector met with on of the organisers who comes into the home three afternoons per week. This person confirmed that they provide a range of activity sessions, which vary, depending on the moods of the residents attending. It was pleasing to see so many residents participating and enjoying these planned activities. Several residents informed the Inspector that they look forward to the activities. The Manager reported that other regular activities in the home continue to take place, including craft sessions, Music in Care Homes who visit monthly, a music for health workshop, reminiscence sessions and musical bingo. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 12 Three Gables has strong links with local religious leaders and residents are able to attend Communion and other services within the home. Residents are encouraged to exercise choice and control over their lives. As examples of choice, residents receive a daily newspaper of their choice, they can choose how to spend their time, and bedrooms are individually furnished and decorated. It was noted in care plans that restrictions on choice and freedom are discussed with relevant parties and guidelines agreed and recorded. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents benefit from an open culture where they are able to express their views and feel valued. EVIDENCE: Three Gables has a complaints policy which is accessible to both residents and visitors to the home. The home has not received any formal complaints in the last twelve months. The residents spoken with all confirmed that they knew how to complain and stated that if they had any concerns they would go straight to either of the owners. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Residents benefit from a clean, comfortable 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 still 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 DS0000021271.V263193.R01.S.doc Version 5.0 Page 15 date. 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. The home was found to be clean, tidy and free from offensive odours on the day of the inspection with the exception of two bedrooms which were slightly malodorous. The Owners had already identified these problem areas and appropriate action was being taken. The two vistors who spoke with the Inspector confirmed that Three Gables is always a clean and pleasant environment to come into. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Residents continue to benefit from the friendly, caring and committed team of staff who work at Three Gables. EVIDENCE: On the day of inspection, the numbers of staff on duty was again reflective of the needs of the residents. Minimum staffing levels provide 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 continues to employ sufficient catering and domestic staff to maintain the running of the home. The Inspector met with seven staff who all confirmed that current staffing levels provided them with enough time to do their job well. Staff also reported that there had been an increase in staff training since the last inspection and that they felt well equipped to perform their roles. Three Gables had an inclusive atmosphere, where there is feeling that people genuinely get on well. At lunchtime, both morning and afternoon staff for the day share a meal together, which helps create a real ‘team’. Residents and visitors again referred to staff as “kind” and “very caring”. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 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 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, 32, 33, 35 & 38 Residents benefit from living in an open, inclusive and well-managed home. Residents would further benefit from formalising the systems of gaining feedback from them and their representatives. Residents are protected by the systems in place to support them with their financial affairs. Adequate systems are in place to ensure the health and safety of residents. EVIDENCE: Three Gables is a family owned and run home and the management team provides two highly skilled and qualified practitioners. The Registered Manager, (who is also one of the Owners) is a Registered General Nurse (RGN), who holds the Registered Managers Award, Advanced Management for Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 18 Care and a Diploma in Gerontology. The other Proprietor is a Registered Mental Nurse (RMN). Both Owners work in the home on a full-time basis. During the week, their hours are supernumerary to the rota and at they each work alternate weekends in a ‘hands-on’ capacity. Staff, visitors and residents all spoke very highly of both Owners, referring to them as “absolutely brilliant”, “very supportive and approachable”. One staff member referred to her induction by the Owners as “I was taught by the best”. At the current time, the home has many informal methods of gaining feedback about the home and ensuring it is run in the best interests of the residents. It is however, required that the home look at ways of introducing a formal system of monitoring quality assurance. The majority of residents at Three Gables either manage their financial affairs independently or with support from their representatives. For those residents that are supported by the home in this area, a record of incomings and outgoings is maintained and entries backed up with receipts. The documentation of this was found to be satisfactory. The health and safety issues identified at the last inspection have been addressed and the only outstanding area is to continue undertaking risk assessments for each room of the home in respect of fire and health and safety. Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X X N/A 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 4 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 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 4 2 X 3 X X 2 Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 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 OP9 Regulation 13(2) Requirement Medication (including controlled medication) to be appropriately adminsitered and recorded and stored at all times. The home to intorduce a formal system of monitoring quality assurance. Risk assessments to be carried out on each room of the home in respect of fire and health and safety. (Previous timescale of 01 October 2005 not met) Timescale for action 04/01/06 2 3 OP33 YA38 24 13(4) 01/04/06 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Three Gables DS0000021271.V263193.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. Extracts may not be used or reproduced without the express permission of CSCI Three Gables DS0000021271.V263193.R01.S.doc Version 5.0 Page 22 - 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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