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Inspection on 24/06/05 for Threen House Nursing Home

Also see our care home review for Threen House Nursing Home for more information

This inspection was carried out on 24th June 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff in Threen House work well together to meet the needs of the service users. The care plans are maintained accurately to reflect the current needs of service users. The home is clean and well-maintained, service users bedrooms are personalised, a comfortable environment is provided for service users.

What has improved since the last inspection?

The Provider/Registered Manager now ensures that the required numbers of Registered Nurses are on duty; the staff rota indicated this. Staff meetings have now been reintroduced enabling staff to discuss general practice issues.

What the care home could do better:

At the time of this inspection a number of key standards were assessed, these standards were being met. Therefore, on this occasion there were no particular improvements identified.

CARE HOMES FOR OLDER PEOPLE Threen House Nursing Home 29 Mattock Lane Ealing London W5 5BH Lead Inspector Susan Woolnough-Singh Unannounced 24th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 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 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 Threehouse@hotmail.com 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 G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Not Applicable Date of last inspection 12th and 18th November 2004 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 hand wash 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 attractice rear garden, The home is within ten minutes walk of Ealing Braodway and West Ealing Stations. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of Threen House. The inspection took place between the hours of 12. 20 and 16.10 on the 24th June 2005. Two requirements and three recommendations were made at the last inspection. The time scale for the two requirements had been adhered to. Eighteen of the key standards were assessed at this inspection. Key standards not assessed at this inspection will be assessed during the next inspection visit. The Inspector spoke with three service users and three relatives as part of the inspection. The relatives/visitors were more able to articulate their views on the home. Relative’s/visitors said that they had looked at a number of homes and Threen House was a clear choice. They commented that the home is kept to a very good standard and that staff treat service users with dignity. What the service does well: What has improved since the last inspection? What they could do better: At the time of this inspection a number of key standards were assessed, these standards were being met. Therefore, on this occasion there were no particular improvements identified. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 6, The Registered Manager ensures that a Needs Led Assessment is in place prior to admitting service users to Threen House, therefore ensuring that the home will be able to meet service users needs. EVIDENCE: The pre admission assessments of two new service users who had moved into the home since the last inspection were seen. These were satisfactory. Intermediate care for older people being discharged from hospital is not available at Threen House. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 A professional care plan package is in use at Threen House. The assessment of need and plan of care is set out clearly. The information seen on each service user care plan was up to date and detailed. EVIDENCE: The Care Plans including the health plans of three service users were seen. The health needs of service users are assessed prior to admission. Health related risk assessments are completed at the time of admission, these are part of the care plan format and cover areas such as tissue viability, moving and handling, service user mobility and body mass index/nutrition. There was evidence on one service users file that a community health nurse was monitoring tissue viability. Visits by health care professionals are recorded. Three service users and three relatives were spoken with in regard to health care needs. Service users and relatives did not voice any particular concern regarding health care standards in the home. A set care plan is available at Threen House; this is comprehensive and covers all areas of service user care. The care plans had been reviewed and updated. Moving and Handling and other risk assessments pertinent to the service users Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 10 care were in place. Service users and relatives spoken with were very satisfied with the care offered at Threen House. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 13 1 4 The programme of activities available provides an interest for service users if they wish to join in. Visitors are welcomed to the home and annual functions are arranged whereby service users, staff and visitors/relatives may socialise. Service users are able to decide on their daily routines. EVIDENCE: A weekly programme of activities is available this is displayed in the dining room. A daily activity is available and a musician visits the home on a fortnightly basis. A monthly Church of England Service is held. Summer activities had been arranged. A strawberry garden party for the Wimbledon tennis semi final was planned for service users and relatives to attend. A summer bazaar had been arranged for August. Service users preferences for activities are recorded in their care plan. It was observed during the inspection that service users had visitors and they were made welcome. The home holds a meeting for relatives, this is well attended and relatives are involved in some decision-making. The minutes for the last meeting were viewed. Relatives had given feedback on outings and the proposal for a landscaped garden. Service users spoken with confirmed they were able to exercise choice in their daily routines. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 18 The information in the complaints procedure gives clear guidance on how service users or relatives may make a complaint. EVIDENCE: Since the last inspection there have been no complaints made at the home or to CSCI. There are two complaints procedures. One complaints procedure is included in the service users guide; this has details of how to contact CSCI. A further complaints procedure is available for service users, listing who may be contacted in case of a complaint. Guidelines for staff on the complaints procedure and process are available in the staff handbook. The home has polices and procedures in place for the protection of vulnerable adults. These policies cover service users money, physical intervention, whistle blowing and adult protection. The homes policies and procedures are covered during the induction period. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 20 23 24 25 26 The standard of the environment in the home is good. Service users are provided with an attractive and homely place to live. The home is well maintained and hygiene standards are good. EVIDENCE: A tour of the home took place. All parts of the home are well maintained and the home is furnished and decorated to a good standard. A spacious lounge and a conservatory are available for service users. There is a large rear garden. The relatives, who hold meetings at the home, plan to eventually raise money to landscape the garden. Service users bedrooms were seen, these are kept clean and tidy and are personalised, some service users had brought in small items of furniture from home. There are single rooms and spacious double rooms. The home was clean in all areas; policies and procedures are available for infection control and clinical waste disposal. Odour control in the home was Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 14 very good. Relatives spoken with commented on the high level of cleanliness in the home. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The staff rota provided to the inspector was clear and easy to follow. The rota indicated that the staffing requirement of staff on duty was being met. EVIDENCE: The staffing levels at Threen House are for two qualified nurses and four health care assistant on during the morning shift. On the afternoon evening shift two qualified nurses and three-health care assistants are required to be on duty. One qualified nurse and two health care assistants are on waking night duty. A cook and domestic are on duty during the day. The rota for the period 19th June to 2nd July was made available to the Inspector. The staff rotas indicated that required number of qualified staff and health care assistants were on duty. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 The home is well managed. The Provider and Registered Manager work together with staff and service users and have a good working knowledge of service users needs and are able to observe and supervise the practice of staff on a daily basis. EVIDENCE: The Registered Manager is a first level registered nurse and and has recently completed the Registered Managers award NVQ level 4. The Registered Manager has been in post for approximately three and a half years. The Registered Manager and the Registered Provider work together to run the home. Both Manager and Provider spend a substantial amount of time working with service users Nurses/Health Care Assistants. Despite the amount of ‘hands on care’ provided by the Manager and Provider the administration in the home appeared to be good, care records and care reporting was of a good standard and up to date. An administrative officer is employed at the home, as part of his duties he is required to process staff personnel records. Staff Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 17 meetings have been reintroduced since the last inspection. The last staff meeting took place on 14th April 2005. The minutes indicate that issues of housekeeping and service users care were discussed. A section of the meeting was used to discuss the purpose and function of the Commission of Social Care Inspection. Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x x 3 3 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 Standard No 16 17 18 Score 3 x 3 3 3 x x x x x x Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard x Regulation x x Requirement Timescale for action x 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. x Refer to Standard x Good Practice Recommendations Threen House Nursing Home G61-G10 s10955 Threen House v214412 240605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing, London W5 2ST 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. 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