Inspection on 24/08/07 for Threen House Nursing Home

This inspection was carried out on 24th August 2007.

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

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

Other inspections for this house

Threen House Nursing Home 15/06/06

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 Jane Collisson Key Unannounced Inspection 10:00 24th August 2007 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.V342907.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 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.V342907.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 26 medical beds for the elderly Date of last inspection 15th June 2006 Brief Description of the Service: Threen House Nursing Home is an attractive, detached house situated in a residential area of Ealing and located opposite Walpole Park. It is registered for twenty six older people. The large shopping centre of Ealing Broadway is nearby and a theatre and cinema facilities are within walking distance of the home. It is within ten minutes’ walk of Ealing Broadway and West Ealing Stations and several bus routes. There is parking to the front of the home. The home has twelve double bedrooms and two single bedrooms, located on each of the four floors. Each bedroom has a wash hand basin. One double room has an en suite facility. There are five bathrooms, located throughout the home, some with assisted facilities and one has a shower. The lounge and conservatory provide both seating and dining areas. The patio and an attractive rear garden are accessed through the conservatory. There is a lift between the basement and the second floor. The home is privately owned and the Registered Provider works in the home on a regular basis. There is a Registered Manager, and team of registered nurses and health care workers. There are two cooks, kitchen assistants, a laundry person, and domestic workers. An accountant/administrator is also employed to deal with finances. The current fees are £685 for shared rooms and £700 for the single rooms. Additional charges are made for chiropody, reflexology, physiotherapy, private optical and dentistry work, toiletries and newspapers. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 24th August 2007 between the hours of 10am and 4.20pm. The Registered Manager was not present and a further visit was made on the 29th August at 2pm to meet with her and to complete the inspection. At the first visit, the Registered Provider and the senior nurse assisted the Inspector with the inspection process, which took a total of eight and a half hours. The home was full on both visits, with one person in hospital. All of the people living in the home were seen. During the morning of the first visit, the physiotherapist was carrying out a gentle exercise session. The visitors of four residents were met and one person had a birthday party in the conservatory, with many family members present. At the second visit, a “music and movement” session was talking place and a large number of people were joining in this. A number of family members were visiting and several people and their visitors were having tea in the garden, enjoying the sunny day. A tour of the home took place with the senior nurse. All areas were found to be very clean, brightly decorated and furnished. The records of residents, staff, recruitment, maintenance and training were sampled. The medication was examined at the second visit to the home. The Provider and Manager completed the Annual Quality Assurance Assessment for the Commission for Social Care Inspection, which provides information about people living in the home, staff and the home’s plans for the coming year. All of the people spoken to, including relatives, were very happy with the care and support they receive from the staff. They commented particularly on the way in which the staff care for the residents, their attitude and friendliness, and the cleanliness and comfort in the home. The home had six requirements at the last inspection, two of which have been repeated in part. A further five requirements have been made at this inspection. What the service does well: What has improved since the last inspection? The majority of the requirements made previous have been met. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 6 Improvements have taken place in the garden and additional seating has been made available. 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. The summary of this inspection report can be made available in other formats on request. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 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.V342907.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 (6 does not apply) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Documentation is in place to assist people to make a decision about the home but additional information is needed regarding how the needs of people who are outside of its category of registration are met. Admissions are not made until a full assessment of need is completed. EVIDENCE: Copies of the updated Service Users Guide and Statement of Purpose were provided. These are combined into a comprehensive document with details of the occupancy agreement. Some people in the home have developed dementia, although their needs appear to be being met at the present time. The Statement of Purpose needs to be amended to show, if they are to remain in the home, how their needs can be met by the staffing, environment and activities. Some information in the Service Users Guide and Brochure was out-of-date in regard to its registration with the Commission for Social Care Inspection and needs to be amended. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 9 The Registered Manager carries out assessments of all new people referred to the home and copies of the documentation she uses were seen. Where people are referred from local authorities a needs-led assessment is received and a sample of these were seen. From the assessment process, care plans are drawn up which are discussed with the person or their family member and are signed. The majority of the rooms are shared and people sign to say they have agreed to this. The home has the facilities to meet the needs of people with some mobility problems as there are lifts to each floor and some bathrooms have assisted bathing facilities. The Registered Manager said that there are plans to convert the bathrooms which do not have assisted facilities and this should be considered to ensure that the National Minimum Standards are met for the number of bathrooms available to use. The Registered Manager has not been confirming to people before admittance, in writing, that their needs can be met. She was advised that this should be carried out, under the Care Home Regulations 2001, and undertook to do this in the future. The home holds a waiting list and people are invited to visit before making a decision about moving into the home. People have the opportunity to visit the home prior to making a decision about whether to live in the home. However, in some cases families have been involved in doing this if the person has not been well enough to do so. Contracts or terms and conditions are issued to all of the people living in the home. There is a four week trial period for those who self-refer and a six week trial period and review for those referred by Social Services. The home does not provide an Intermediate Care unit, so this National Minimum Standard is not assessed. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are involved in care planning. Care plans have been extended to take account of a wider variety of activities. Risk assessments are in place but are not always sufficiently detailed to explain how people might be placed at risk and the risks reduced. Systems are in place to try and minimise medication errors but more consistency is required among the staff responsible to ensure consistency of recording. Residents have access to a range of medical and health professionals EVIDENCE: The home uses a commercial system for its care plans, which includes a variety of assessments, recording sheets and other documentation. One set is in place for each person and a sample of four was examined. From the various assessments, which include moving and handling, falls and nutrition, care plans are compiled. The resident or their representatives signs these. Since the last inspection, the home has added those on nutrition and falls in response to requirements made then. The home has also added an extra care Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 11 plan for “work and play” to record the social history and the activities and lifestyle that the resident enjoys. Risk assessments are in place for manual handling. While permission was seen to have been given when restrictive procedures, such as using bed sides, are in place, the risk assessments did not record in sufficient detail any risk which may be present, such as the person trying to climb over them. The senior nurse said that people are always assessed, but the risk assessment needs to be shown to have considered all of the potential hazards and to have discussed with the resident or their family the risks involved. The Registered Manager said that she had already been looking for a more comprehensive risk assessment format to use for this purpose. The Registered Manager said that Local Authorities now carry out annual reviews for the people placed with them, which had not always happened in the past. A number of general practitioners visit the home. Notes of any visits are recorded in the person’s file and examples of these were seen. One person has enteral feeding and one has insulin injections. Training in insertion and maintenance of the peg feed was given in February 2006. Where people have been admitted with pressures sores, photographs have been taken. One person was admitted from hospital with wounds on the legs and has been treated successfully. People were noted to be on special mattresses where they were felt to be at risk. The senior nurse has responsibility for wound care and is the home’s liaison person for tissue viability with the Primary Care Trust. Chiropody is carried out privately and visits are made every eight weeks. The files showed that people have access to opticians and dentists as required. The Registered Manager said that a Community Psychiatric Nurse had been accessed when required and a successful intervention had been made to ensure that the person concerned could remain in the home. The home has the services of a local pharmacy to supply its medication, which is supplied in bottles and packets. The Commission for Social Care Inspection’s pharmacy inspector previously visited the home in 2005 to examine the medication systems and her requirements and recommendations were being followed. However, the home has a number of systems to keep track of the medication. Only one of the general practitioners supplies the medication on a monthly basis, for eight of the residents, the remainder renewing prescriptions at different times and not always giving 28 days supply at a time. In the sample of medications checked, it was noted that packets had an “opened” date recorded on them. This was not necessarily the day the medication started. Because the medications are issued in different amounts, Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 12 at different times, one resident could have a variety of “start” days. This caused some confusion as stock did not always tally and, in a sample of three peoples’ medications, each had tablets which had one short or one too many. In one instance, the staff member dating the medication had made two errors with the dates. Although there is a second recording book being used to record the date the medication was put into stock, the system is overcomplicated and does not aid good monitoring. The Registered Manager said that they and the pharmacist had tried to get a more regular system introduced with the general practitioners but this had not been successful. Further efforts should be made to do so and it is advised that the staff look again at a less complicated recording system. The Registered Manager was also asked to ensure that the staff understand the system being used to date the opening of the medication packets and that regular monitoring takes place to ensure they are following it. It was noted that audits had been carried out in December 2006 and July 2007. These need to be carried out more frequently to identify the type of errors found by the Inspector. The way in which people were observed to be treated was polite and kind. One visitor observed that, even when staff were not aware of the presence of a visitor in the immediate area, they were invariably respectful in the way in which they conducted themselves with the residents. Privacy is provided in shared rooms by screen and there are sufficient bathrooms were people may be bathed or washed in private should this be required. The staff said that people are asked for their wishes on same gender personal care when they arrive at the home. There are few male staff, so female support is usual. However, it should be noted in care plans where residents have preferences. It should also be borne in mind that some people may not like to object when they are first admitted. It is recommended that same gender care is provided for female residents unless a positive preference is made otherwise. Information was seen in the care plans as to who the staff would contact in the event of serious illness or death. People’s wishes with regard to cremation or burial were recorded and their religion, if any, is noted. This should be extended to discussing, wherever possible, people’s wishes in regard to a terminal illness, for instance, and if there are any specific needs, such as a priest, they would wish to attend. It is recognised that not all of the people will wish to discuss this, but families could be involved where this is appropriate. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A regular programme of activities is available to provide interest and stimulation. Visitors are very welcome and provide support to the home and its residents. Meals are satisfactory but do not provide a selection of dishes from which residents can choose. EVIDENCE: Although the home does not employ an Activities Organiser, a variety of activities are offered. On the first visit, the physiotherapist was carrying out a gentle exercise session for a group of residents. These sessions are on a fortnightly basis and alternate with a reflexologist. There is a charge for these sessions, which is detailed in the brochure and Service Users Guide, although the costs of these should also be included. Other residents were in the lounge or conservatory, watching television or reading newspapers. Music and movement sessions are also held regularly and one was taking place on the day of the second visit. The home has a leisurely atmosphere and some people were still having breakfast quite late during the morning of the first visit to the home. People confirmed that they were free to do as they wish, but the majority choose to Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 14 spend their time in the communal areas. Some people said that they go to the local shops with their families, but not usually with the home’s staff. This might be an activity which could be offered. The visitors of five of the families were met during this inspection and they, and the staff, confirmed the involvement that they have with the home. In some instances, a number of people whose relatives have died continue to support the home with their social and fund raising events. The garden furniture has been provided through fund raising and a bazaar has been held on the Saturday prior to this inspection. A fireplace in one of the communal areas had been another welcome addition provided by fund raising. A large number of family members were present on the first visit to celebrate the birthday of their relative. Visitors were able to meet more privately with their relatives using the garden, as the weather was pleasant. While there is no separate, private communal space for visitors, and the majority of the rooms are shared, visitors said this is not a concern. The Registered Provider has plans to extend the conservatory once the planning application is agreed, which should provide additional space to meet. There are additional regular entertainments, including a musical entertainer. The hairdresser visits fortnightly. An outing to Kew took place in June and another is planned to Richmond Park in September. A cream tea was also being advertised for residents, relatives and friends in September. Some people enjoy reading newspapers and books, and the mobile library visits for one person. The home also has a good stock of large print books. Although the residents prefer not to have bingo, some have requested art sessions and this is being considered. One person goes to church with family members. There is a mass each month within the home and a communion is undertaken weekly by a Sister from the church. There were no other cultural or religious needs to be met at the present time. Residents were generally positive about the meals provided in the home. There is no displayed menu and, while people confirmed that alternatives were available if they did not like the meal offered, one person said that this was usually a cold alternative, such as ham. It is recommended that the home has a displayed menu, preferably in large print. People should be able to make a positive choice from two or more alternatives and, for variety, salad could also be added. Diabetic meals were the only specialist diets required at the time of the inspection, although staff said that they had catered for appropriate cultural diets in the past. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were confident that any concerns they had would be dealt with by the management appropriately and felt free to express their views. Regular meetings provide the opportunity for discussion with relatives and residents. Staff are trained in adult protection issues. EVIDENCE: The Registered Manager confirmed that no formal complaints had been made since 2004. Where any concerns are raised, the staff try to address them immediately. Those residents and relatives spoken to during the course of the inspection said that they would be willing to complain, should this become necessary, but felt that they could discuss their concerns with the Registered Provider or the Registered Manager and get them sorted out at the time. One person remarked that they would be “disappointed” if complaints were made as they felt the care was excellent and there was nothing to complain about. There have been no safeguarding adults issues raised in the home. Staff are trained in the protection of vulnerable adults and the training matrix showed that all of the staff had training in July 2007. The Registered Manager, Registered Provider and senior nurse have all attended an awareness day at run by the Safeguarding Adults team in Ealing. The Registered Manager said that she brings up issues with her staff team to help them to understand the various aspects of abuse. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A pleasant and well-maintained environment is provided and people live in safe, comfortable and clean surroundings. People are encouraged to personalise their bedrooms. Not all of the bathrooms have appropriate adaptations and aids and would benefit from upgrading. EVIDENCE: The home continues to be well maintained and was clean and odour-free. There are bedrooms located on all four floors of the home, and each floor has at least one bathroom and toilet. The home has a large garden, which had recently been landscaped. In addition to the patio, there are areas where residents can walk and an enclosed pond to be enjoyed. New garden furniture had been provided from fund-raising efforts and there is sufficient space throughout the garden for residents and their visitors to enjoy a degree of privacy. At the second visit, which was on a Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 17 sunny day, several people were using various areas of the garden to meet with the families, or with other residents. While the majority of the bedrooms are shared, the rooms seen were all quite large and all provide an area with shelving for each person to personalise. Rooms are individually decorated and provide bright and cheerful spaces. Each room has a washbasin, and screens are available for privacy. The rooms are not all large enough to have the items that should be offered under the National Minimum Standards, such as two chairs and a table. However, staff said that extra seats are available should someone wish to see visitors in their room. A number of people have walking frames and some have wheelchairs to get around the home. The lift stops at all floors, from the basement where there is one bedroom, to the second floor, where there are four and there is level access in all areas of the home. There are five bathrooms, although two have no equipment and could only be used by people who are very mobile. The Registered Manager said that these are not used at present. There is a shower room and two baths with chairs. Consideration should be given to providing all of the bathrooms with some suitable equipment to minimise any risk to the residents or the staff. The Registered Manager said that the Registered Provider is considering this and an Action Plan should be provided so that a reasonable timeframe is being considered. There are separate changing and toilet facilities for staff and they have a small staff room in the basement. There was one domestic staff on duty and all areas of the home were found to be very clean and there were no malodours in any area. There is a sluice room and the laundry room was found to be orderly. The Registered Manager said that the Registered Provider had taken the suggestion from a resident that some of the carpets needed replacing and this was being carried out. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives have confidence in the staff to provide a good level of care and support. There is a regular programme of training. Sufficient staff are on duty to meet the needs of the people living in the home. The recruitment process does not meet all of the National Minimum Standards or Care Home Regulations 2001 and needs revision. EVIDENCE: The home’s rota was examined and showed that two registered nurses are available on each of the early and late shifts, with four health care assistants in the morning, and three in the afternoon and evening shift. The night staff comprises of a registered nurse, and two health care assistants. This appeared to be sufficient for the twenty six people who reside in the home. The home employs, as health care assistants, nurses from overseas who are carrying out their adaptation training at a West London college. One was being employed currently and two student nurses were undertaking eight week placements in the home. There was one staff vacancy and a number of the staff who were spoken to had worked in the home for more than seven years. This has provided good continuity for the residents. Staff were appreciative of the home and its management and said that they enjoy working there. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 19 It was a previous requirement that all of the staff are required to have the basic training courses. The matrix provided showed that all of the staff had upto-date training, including manual handling which had been undertaken in April 2007. There had not been a full induction procedure in place at the last inspection and the Registered Manager has introduced a “Skills for Care” induction which the staff who had more recently commenced work were seen to have completed. They had also undertaken all of their basic training. A sample of four staff records were examined. It has been a requirement that the recruitment procedures were improved in relation to obtaining references. However, there were still found to be improvements needed. The application form does not provide for a full employment history to be completed with dates, employers and experience. These are needed both to safeguard people and to provide the home with sufficient information to obtain appropriate references. A more comprehensive application form should be introduced so that prospective employees are aware of the information they must provide. This should include the reasons they left their previous employment. Those references, which were seen in one of the files, had no indication as to whether they were from employers or colleagues. The “right to work” was not seen in one of the files examined and the Registered Provider was asked to ensure that this is available. He was also recommended to expand the list at the beginning of each file to show when references has been obtained and it appeared that one person may have commenced before the references had arrived. The Criminal Records Bureau disclosure number should also be included so that the information could be examined if the senior staff were not on duty. The Registered Manager maintains a file of nursing PIN information so that the renewal dates can be checked. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, with a high level of involvement from the Registered Provider which helps to provide an open and transparent service. The risk assessments procedures and medication administration still require better monitoring to ensure compliance. EVIDENCE: The Registered Manager is a RGN and has the Registered Managers Award, including the National Vocational Qualification Level 4 in Care. She has been the Manager for five years, having worked previously in the home on night duties since the home opened in 1993. The Registered Provider works in the home on a regular basis, sometimes as part of the rota, and has undertaken a wide range of training, including National Vocational Qualification Level 3. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 21 The home has a very pleasant and open ethos with staff having an excellent rapport with the residents and their families. The visitors remarked on the atmosphere of the home, which they find welcoming and said that they find staff very approachable. Surveys are given out regularly and the results of 48 have been recorded since May 2004 from residents and families. While the results demonstrated that the people feel the home is good or excellent, they need to demonstrate how any comments have been incorporated into the home’s improvement plan and its future development. The Registered Manager said that there had been instances where comments have been made, such as carpets being “tired” and needing to be replaced, and this is in hand. A file to record quality assurance monitoring is in place, but has not been fully utilised to provide a comprehensive development plan. The accountant/administrator was on holiday at the time of the inspection but the Registered Manager confirmed that the home does not generally hold money on behalf of residents and invoices them, or their families, for any charges that are incurred. One person has their money managed by the Public Guardianship office. The Registered Provider acts as the appointee for one person who has no family but said that this would not be undertaken in the future. A file of staff appraisals and supervision notes was available for inspection. All of the staff had received an annual appraisal and records sampled showed that staff had attended two sessions this year. The Registered Manager said that she hopes to meet the National Minimum Standard of six sessions a year and had a schedule of the next sessions, which are undertaken by herself, the senior nurse and the night staff nurse. The current fire risk assessment was compiled in January 2007 but does not meet the requirements of the new legislation, which came into force in October 2006. This was discussed with the Registered Provider and it will need to be updated, taking into account any specific needs caused by the home’s environment and the disabilities and mobility of its residents. The Registered Provider said that the home is a “no-smoking” area throughout and that staff and visitors only smoke in the garden. A sample of maintenance records was examined. The fire alarms did not appear to have always been tested on a weekly basis and the risk assessment needs to show the frequency of the tests, maintenance and servicing. The Environmental Health Officer last visited the home in August 2005. The Registered Manager gave information on the Annual Quality Assurance Assessment of the dates of the maintenance of equipment. The lifts were serviced in July 2007, the hoists in May 2007 and the gas appliances in April 2007. However, the files did not always contain the last record or invoice for the servicing and these need to be kept up-to-date for inspection. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 22 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 3 3 2 X 3 3 X 2 Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 4 (1) Requirement The Registered Manager must ensure that the home’s documentation is up-to-date and contains information on how the needs of people who do not fall into its category of registration are met. This must include the facilities and services for those with dementia. The Registered Manager must ensure that risk assessments, including those for bedsides, clearly show all of the potential risks and that residents and their relatives are appraised of these before being asked to sign their agreement. The Registered Manager must ensure that all staff who record and administer medication are fully conversant with the system for opening and dating medication. Regular monitoring must take place to ensure that errors are not being made with the recording. The Registered Provider and Registered Manager must ensure that the residents have a variety DS0000010955.V342907.R01.S.doc Timescale for action 30/09/07 2 OP7 13 (4) (b)(c) 30/09/07 3 OP9 13 (2) 30/09/07 4 OP15 16 (2) (i) 31/10/07 Threen House Nursing Home Version 5.2 Page 24 5 OP29 19 (a)(b)(c) Sch. 2 6 OP33 24 (1) (2) 7 OP38 23 (4A) (b) of choices for their meals, rather than a daily alternative to the main meal. These should be informed by consultation with the people living in the home. The Registered Provider and Registered Manager must ensure that no staff are employed who have not provided the full information required under the Care Home Regulations 2001 and for whom the relevant references, and other employment documentation, has been obtained. (The previous timescale of 1/09/06 not fully met). The Registered Manager must ensure that there are regular reviews of the quality of care which reflect the views of the residents. (The previous timescale of 01/10/06 not met) The Registered Manager must ensure that the fire risk assessment is fully completed in accordance with the fire legislation (Regulatory Reform [Fire Safety] Order 2005) which came into force in October 2006. 30/09/07 31/12/07 31/10/07 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 OP10 Good Practice Recommendations That residents are asked on a regular basis regarding their preference for same gender care and their representatives are consulted where this might be difficult for the resident to make a decision. That more information is recorded, wherever possible, about the wishes of the residents, including their religious DS0000010955.V342907.R01.S.doc Version 5.2 Page 25 2 OP11 Threen House Nursing Home 3 4 OP12 OP21 5 OP29 and cultural needs, in the event of serious illness, dying or death. That there is a more visible display of the menu on offer to enable involvement and choice. That at least one of the bathrooms without equipment is converted to a shower room or assisted bath, to ensure there is a variety and sufficient bathrooms for the number of residents. Residents should be involved in the decision making. That a checklist is introduced showing the dates on which recruitment checks are carried out and the information received. Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Threen House Nursing Home DS0000010955.V342907.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!