Inspection on 15/06/06 for Threen House Nursing Home

This inspection was carried out on 15th June 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 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

Threen House Nursing Home 24/08/07

Threen House Nursing Home 30/11/05

Threen House Nursing Home 24/06/05

Threen House Nursing Home 12/11/04

Threen House Nursing Home 24/08/04

Threen House Nursing Home 03/12/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Threen House Nursing Home 29 Mattock Lane Ealing London W5 5BH Lead Inspector Ms Susan Woolnough-Singh Key Unannounced Inspection 16.30 15th June 2006 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 Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 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. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Threen House Nursing Home Address 29 Mattock Lane Ealing London W5 5BH 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) 020 8840 2646 Mr Alan Hannon Ms Pamela Ruby Anne Watson Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 26 medical beds for the elderly Date of last inspection 30th November 2005 Brief Description of the Service: Threen House Nursing Home is an attractive detached house located opposite Walpole Park. The home consists of twelve double bedrooms and two single bedrooms. Each bedroom has a wash hand basin. One single room has an en suite facility. There is a lounge/dining area with a conservatory that provides access to a patio and an attractive rear garden. The home is within ten minutes walk of Ealing Broadway and West Ealing Stations. There is a large shopping area in the Ealing Broadway area. There are theatre and cinema facilities within walking distance from the home. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection of Threen House. All of the Key Standards for Older People were assessed. The inspection took place on 15th June 2006 between 16.30 and 20.00 and 21st June between 10.15 and 17.00. Inspection feed back was given to the Proprietor and Registered Manager on 22nd July 2006. As part of the Inspection a tour of the home was carried out, service user plans and staff records were viewed. The Inspector spoke with two relatives and the Chairwomen of Residents Relatives Group. The Inspector spoke with three service users with regard to the care they receive at Threen House. What the service does well: What has improved since the last inspection? What they could do better: The service users plans viewed were generally comprehensive. The format of the plan concentrates on the assessment and care plan for the physical well being of the service users. Additional information on the social care needs of Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 6 service users will be of benefit. A formal quality assurance system will enable the home to plan for any improvements required on a yearly basis. The complaints procedure would benefit from being provided in a large print format. 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. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 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 Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users move into the home with a full assessment of their needs. EVIDENCE: The Assessments of four service users were seen. If a Local Authority places the service user a Needs Led Assessment is forwarded to the home prior to admission. The home also has an assessment that is completed; a continence assessment has been added since the last inspection. The home does not offer an intermediate care service. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 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 8 9 10 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service users plans were comprehensive, the Registered Manager needs to ensure that updates and reviews are clearly recorded. The service users spoken with felt that they were treated with dignity and respect, the comments of one service user were passed on the Proprietor by the Inspector. The Medication system has been updated and improved as required at the last inspection. EVIDENCE: The Care Plans of four service users were seen. The Stanex System of care planning is used at Threen House. The format combines an assessment, the care plan, and information of the service users health care needs. The care plan provides overall information on the needs of the service user. A dependency profile is completed for service users. The care plan also has a Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 10 section for recording activities undertaken by the service user. A requirement was made at the last inspection for the care plans to be kept up to date; this had been done although when looking at the care plans it was not always clear which date was the most recent review date for care planning and health care assessments. The Inspector noted that one moving and handling assessment was dated January 04. This was mentioned to the Registered Manager who pointed that this care plan had been reviewed in June 2006. The care plans are comprehensive but it is to be recommended that the care plan paperwork work be reviewed to ensure that recent review dates are evident. The Inspector was informed that a named nurse (RGN) is responsible for ensuring paper work is kept up to date. Assessment information is recorded on the care plan for tissue viability, moving and handling, and continence and catheter care. There is a section on the plan where the visits of health care professionals may be recorded. For service users who require bedrails and protectors the General Practitioner and family give consent. A General Practitioner visits the home; other health care services such as chiropody and optical care are available on a private basis. Mental Health referrals are made through the General Practitioner if required. A letter seen from a Consultant Psychiatrist indicated that the staff had worked professionally with a service user who needed special care. Dietary supplements are ordered for some service users through the Dietician. A monitoring chart for the giving of supplements has been prepared. At the time of the last Inspection the Commission for Social Care Inspection Pharmacist assessed the medication system. Eight Requirements were made for the improvement of this system. The Inspector confirmed with the Registered Manager that the necessary corrective action had been taken. New medication policies include non-compliance with medication administration, and policies on covert medication and home remedies. Systems are in place for the ordering of medication and checking in new medication, this procedure is carried out by two nurses. A Pharmacy Inspector from Ealing Primary Care assessed the system on 20/03/06; the report seen did not highlight any particular concerns. The Inspector spoke with three service users and three visitors to the home on the subject of the care provided in relation to privacy and respect. The comments from two service users indicated that the manner in which they are cared for is satisfactory. One service user had a concern about a member of a staff and his/her manner. The Inspector discussed this with the Proprietor who consequently spoke with the service user about his/her concerns. The last staff meeting was held on 30th May 2006. A copy of the minutes was given to the Inspector. One agenda item was ‘Standards within the organisation and Best Practice’. The topics discussed were interpersonal skills, body language, communication skills and courtesy when working with service users. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 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 13 14 15 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are available in the home and a good programme of outing is arranged. Information on service users individual needs must be added to the care plan. Service users are able to maintain contact with family and friends and are able to make choices within the schedule of the home. Relatives and service users were generally pleased with the service offered. A variety of meals are offered and individual service user s dietary needs are catered for. EVIDENCE: An activities programme is available. Activities are available in the home such as movement to music and musical entertainment. External activities are also arranged. A trip to the theatre had taken place on 26th May 2006 and a trip to Syon House and Butterfly House on 9th June 2006. Future summer trips are planned and activities are planned; a summer bazaar and a garden party and a trip to the Walpole festival. The three relatives spoken with one confirmed Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 12 that music and keep fit sessions are held; one relative was very pleased that the staff try hard to keep her mother active. Activities participated in are recorded on the care plan. The care plan although comprehensive does not set out the individual social care activities that service users will be offered. Information must be included in the care plan on how this need will be met. The three service users spoken with confirmed that they had their routines and choices. Some services users have breakfast in bed and one service user said he/she chose not to join in organised activities. One service user was particularly proud of the garden, which had just been altered and replanted. Relatives spoken with talked highly of the home and the level of care. Two relatives indicated they were very pleased with the way in which staff had worked with their relative (service user). One relative said staff had managed a problem in a very professional manner. One relative commented that the home was remarkably well administered. There is an active Relatives Residents Association. Joint planning takes place for the use of finances raised for service users and the planning of activities. Regular meetings take place whereby the views of relatives and service users can be aired to the management of the home. Visitors are welcome to the home and the Inspector was able to observe visitors being treated in a friendly manner. The home was quite busy on the days of the Inspection as has been the case on previous inspections. Service users spoken with were satisfied with the food, one service user said that food was served in a suitable manner for people’s requirements. Individual records of each service users dietary intake are maintained. The menu was seen, this mainly consisted of traditional British main meals and puddings. A light tea is served in the evenings. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 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 18 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure; this could be further improved by offering this in large print. Staff have received training to make them aware of the issues relating to the protection of service users. EVIDENCE: The home has a clear complaints procedure, which provides contact details for the home and the CSCI. The Complaints Procedure is in small print, it is to be recommended that this be reviewed and be available in large print. One complaint had been received since the last inspection. The Inspector was able to see the complaint correspondence and investigation record. The complaint had been dealt with in a satisfactory manner. Protection of vulnerable adults procedures were in place. There is a Whistle Blowing Policy for staff. Staff have received training in Dementia/Abuse and Protection of Vulnerable Adults. A policy is available for Management of Service Users Finances. The home collects the personal allowance for some service users, for others this is collected by relatives. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 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 20 21 23 24 26 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is very good providing service users with an attractive and homely place to live. The high level of house keeping is to be commended. . EVIDENCE: The Inspector carried out a tour of the building. The décor, fixtures and fittings are to a good standard. Bedrooms had been personalised and looked homely. Since the last Inspection a fireplace has been fitted with money raised for service users. The fireplace is of a traditional cast iron with a gas flame effect. Old-fashioned kitchen memorabilia has been place on top of the fire. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 15 The communal space in the home meets the needs of the service users. There is a communal sitting room with dining space in the conservatory area. Work has taken place to improve the garden since the last inspection. An attractively planted walk way to the rear of the garden has been created. Service users have sufficient and suitable lavatories and washing facilities. Only one area of the home is in need of attention. An action plan for work to be carried out to the bathroom adjacent to the office must be forwarded. The lino needs replacing and the woodwork would benefit from redecorating. There is a good standard of hygiene in the home. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 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 28 29 30 The Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was adequately staffed to meet the needs of the service users. An organised recruitment and selection process was in place to ensure that staff are suitable for the post. All applications must be supported by two references requested by the employer. A good training programme is in place to meet the needs of service users; the new Induction Course for new staff must be commenced to improve staff skills when they join the establishment. EVIDENCE: The home was appropriately staffed at the time of the inspection. During waking hours there are two registered nurses and four health care assistants on duty in the morning and two registered nurses and three health care assistants on duty in the afternoon and evening. One registered nurse and a health care assistant are on duty during the night. There are thirteen-care assistants employed at the home. Seven care assistants have completed the NVQ level 2 in care. The home has not employed any new staff since the last inspection; adaptation nurses only have joined the staff team. The files of three adaptation nurses were sampled to assess the quality of staff records. An application form, Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 17 references and a CRB check were available on the files sampled. On the file of one member of staff one of the two references was dated 2001. The Inspector was informed that from September 2006 the process for placement of adaptation students from overseas will be changed. Adaptation students will be processed through the college they are attending and be allocated work placements. The home will no longer be responsible for the interview and selection process. At the time of the inspection two adaptation nurses who were linked to Thames Valley University had placements at the home. A Thames Valley University Audit had recently taken place; the aim of this was to assess the learning environment for students. The skills for care Induction training paperwork is soon to be introduced for new staff. New staff have not yet commenced with this training. There was no evidence of an Induction course for the two of the adaptation students. The Inspector was provided with a Training chart for Threen House. Staff have received mandatory training in health and safety subjects relevant to their tasks. (Please see standard 38) The chart indicated that staff had received skills training relevant to the care of older people. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 The 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 and administered for the benefit of service users. This was borne out by service users and visitors who spoke highly of the home. The systems of quality assurance need to be kept up to date to ensure that the home is able to carry out an internal audit and take into account the wishes and needs of service users. Procedures are in place for the management of service users monies. Overall, systems for the management of health and safety throughout the home are good, thus safeguarding service users. A training programme for skills related to health and safety are in place although it must be ensured that all staff have the opportunity to attend the mandatory training. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 19 EVIDENCE: The Registered Manager is a qualified nurse and has been in post for a number of years. She has the Registered Managers Award and has the skills and competence to administer home to provide a good standard of care for service users. Service users and their relatives are able to put their views forward in regular meetings with the provider and the Registered Manager. A formal Quality Assurance System is not available. This would encompass a regular audit of the home and the publication of service users survey results. A Policy for the Management of Service Users Personal Allowance is available. For the majority of service users personal allowance is managed either by Social Services or service users representatives. Financial records were not examined on this occasion. Systems are in place for the management of Health and Safety. The home provided information in the form of the Pre Inspection Questionnaire. Regular servicing of equipment has taken place. Risk assessments are place, which cover most areas of the home and risk related tasks. A comprehensive fire risk assessment has been developed. Evidence was in place to demonstrate that regular health and safety checks are carried out and recorded. Training is provided to staff in moving and handling, food hygiene, infection control, fire safety and first aid. The majority of staff have received this training. The records seen by the Inspector indicated that some staff were yet to undertake this training. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 2 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x X 2 Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 21 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 OP12 Regulation (2)(m) &(n) Requirement Care plans for each service users social and leisure interests must be formulated and reflect their individual needs and identify how these are to be met. The timescale of 1/1/06 set at the last inspection was not met. The service user plan must be kept up to date. The employer must request all references sought for a prospective employee. All new care staff must receive induction and foundation training which meets recognised training standards. A Quality Assurance System must be put in place reflecting the views of service users. All staff must undergo mandatory training in moving and handling, infection control and food hygiene and Fire Safety. Timescale for action 01/10/06 2. 4 5 OP21 OP29 OP30 23 (2) (d) 19 (a) (b) 18 01/10/06 01/09/06 01/10/06 5. 6. OP33 OP38 24 (1) (2) 18 (1) (a) 01/10/06 01/11/06 Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 22 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 OP7 OP16 Good Practice Recommendations The care plan paper work should be reviewed to ensure that it is clear which date comprises the last assessment date for the various areas of the care plan. The Complaints Procedure should be provided in large print. Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Threen House Nursing Home DS0000010955.V288517.R01.S.doc Version 5.1 Page 24 - 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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