Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 30/11/05 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 30th November 2005.

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

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

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

What has improved since the last inspection?

There were no requirements or recommendations set at the last inspection.

What the care home could do better:

The service user plans viewed were generally comprehensive. Some additional information plus reviews of some assessments to ensure the documentation provides an up to date picture of each service users needs was required. Service users hobbies and interests also need to be ascertained and included. Medications are generally well managed, however some shortfalls were identified and are to be addressed. Shortfalls identified with the staff employment records gave cause for concern and need to be addressed as a matter of priority. A matrix for staff supervision and for staff training would enable the home to view at a glance up to date information for both areas. Fire safety management needed reviewing to ensure that fire drills and the fire risk assessment are up to date.

CARE HOMES FOR OLDER PEOPLE Threen House Nursing Home 29 Mattock Lane Ealing London W5 5BH Lead Inspector Mrs Clare Henderson-Roe Unannounced Inspection 30th November 2005 01:30 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.V269635.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 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.V269635.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 26 medical beds for the elderly Date of last inspection 24th June 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.V269635.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 12 hours was spent on the inspection process. One Inspector carried out a tour of the home, and service user plans, staff records, financial records, maintenance and servicing records were viewed. 8 service users, 3 staff and 1 visitor were spoken with as part of the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 6 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.V269635.R01.S.doc Version 5.0 Page 7 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. The home does not provide intermediate care. Service users are assessed prior to admission to ensure the home can meet their needs. EVIDENCE: The home has its own pre-admission assessment form. Two were viewed and one had been clearly completed. Social Services needs led assessments were also available for both service users and these gave a clear picture of the service users needs. The Inspector recommended that the Registered Manager review the home pre-admission assessment document and add any pertinent information requirements, such as tissue viability status. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 8 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 and 9 Overall the service user plans were comprehensive, with some updates required to ensure staff have an up to date picture of the service users needs and how these are to be met. Medications are generally well managed, however shortfalls could potentially put service users at risk. EVIDENCE: One Inspector viewed three service user plans. Overall these were up to date and gave a good picture of the service users needs. There was evidence of updates to reflect changes in a service users needs plus monthly reviews had been carried out. One care plan viewed required updating to reflect a change in care, and this was discussed at the time of inspection. Risk assessments for falls had been completed in the risk assessment section of the service user plan. One fall was tracked and the falls risk assessment had not been reviewed and updated following the fall. An accident form had been completed and an entry had been made in the daily record. This was discussed at the time of inspection. Wound care documentation was comprehensive and showed the progress of wound care management. Input from the Tissue Viability Nurse Specialist was recorded. The recording of pressure relieving equipment in use was discussed Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 9 and documentation reviewed to include this. Nutritional assessments had been carried out and care plans to address any nutritional needs formulated. Moving & handling assessments were in place and identified the equipment to be used for each individual. One required updating to reflect the loss of mobility of a service user. Care plans for continence care needs had been formulated, but continence assessment documents were not included in the service user plan. This was discussed and these need to be acquired and completed for each service user, to reflect their current continence status. Consents for the use of bedrails had been obtained. The risk assessment entries for the use of bedrails were somewhat brief and did not show that full assessment had taken place. The need to formulate a clear and comprehensive risk assessment for the use of bedrails, to evidence the reason for and appropriateness of their use in each individual case, was discussed. All service users are registered with a GP and there was evidence of input from other healthcare professionals. The CSCI Pharmacist Inspector carried out an inspection on 30/11/05 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 10 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 and 15 Information regarding service users interests and hobbies needs to be sought and recorded so that their individual needs can be planned for and met. The meals in this home are good, offering variety and catering for individual dietary needs. EVIDENCE: An activities programme was available in the day room. No care plans for service users individual hobbies and interests were available. A coded entry of any activities undertaken by service users is recorded, but this did not evidence any individual interests being pursued. This area of care needs to be addressed so that the home can formulate an activities plan to include service users individual interests. The kitchen was clean and tidy and kitchen records viewed were up to date. Individual records of each service users dietary intake are maintained. If a service user does not wish to have the main meal of the day, then alternatives are always available and the cook has a good knowledge of each service users likes and dislikes. The lunchtime meal was observed, and service users were socialising and enjoying their meals. Staff were available to assist service users in a sensitive manner. Service users spoken with said that they enjoy the food provision at the home. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 11 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 and 18 The home has a satisfactory complaints system in place and service users feel that any concerns are listened to. Staff have knowledge and understanding of adult protection issues which protect service users from abuse. EVIDENCE: The home has a clear complaints procedure, which provides contact details for the home and the CSCI. No complaints had been received since the last inspection. Service users spoken with said that any concerns are listened to and addressed. Protection of vulnerable adults (POVA) procedures were in place and the Registered Manager said that staff had received training. Staff spoken with showed a clear understanding of POVA and Whistle Blowing procedures, and said that they would report any concerns. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 12 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, 23, 24 and 26 The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: One Inspector carried out a tour of the home. The décor was to a good standard and bedrooms had been personalised and looked homely. A copy of the redecoration and refurbishment plan for the year with timescales for completion has been forwarded to the CSCI. 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. The garden is well maintained and is accessible from the day room area. The home has twelve double and two single bedrooms. Screening is available in all the double rooms, and the potential of sharing a room is discussed with prospective service users and agreements to share are signed. Each bedroom has a suitable lock and service users can have the keys if they so wish. Each service user has a lockable drawer provided. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 13 The home was clean and tidy. There were personal toiletries left in the bath and shower facilities and this was discussed at the time of inspection. A separate sluice room is available and this was clean. Gloves and aprons were available throughout the home. The laundry room was clean and tidy. All clothing viewed was appropriately labelled. Soap and towels were available in all areas where service users, staff and visitors may require to wash their hands. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 14 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 and 30 The home was adequately staffed to meet the needs of the service users. The processes of vetting and recruitment were not robust and appropriate checks had not always been carried out, thus potentially leaving service users at risk. Staff had received training, but this needed to be evidenced to ensure that the staff receive all the training they require to meet the needs of the service users. EVIDENCE: The home was appropriately staffed at the time of inspection. The staffing roster evidenced that the home ensures that there are enough staff on duty to meet the needs of the service users. The Registered Manager reported that 10 care assistants had completed the NVQ level 2 in care. Two staff employment files were viewed as part of the inspection. Both application for employment forms viewed did not detail previous employment or reasons for leaving the employment. Referees identified in the application form were not always the people from whom the written references had been obtained. Criminal Record Bureau and POVA first checks had not been obtained in either case, with Criminal Records Bureau checks from the employees’ previous employment having been accepted. This practice was stopped in July 2004 and this was discussed with the Responsible Individual. In addition, the Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 15 need to obtain enhanced Criminal Records Bureau checks for all employees who have contact with service users was also discussed. Foundation training was available. An in-house induction programme was available, but this did not meet the Skills for Care (formerly TOPSS) core standards. There was evidence that staff were receiving training, however there was no overview of the training undertaken in the last year. It was suggested that a training matrix, to provide easy reference to the training for each member of staff, be formulated, and the Registered Manager said that she would do this. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 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 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): 35, 36, 38 and aspects of 33 The systems for quality assurance need to be kept up to date to ensure that the home moves forward in line with the wishes and needs of the service users. Service users monies are well managed and secure procedures are in place. Staff receive supervision, thus promoting communication and review of practice. Overall, systems for the management of health and safety throughout the home are good, thus safeguarding service users, staff and visitors. The exception is the fire safety management, which needs to be reviewed to ensure all aspects are kept up to date. EVIDENCE: Service users satisfaction questionnaires had been undertaken but it was unclear as to how recently this had taken place. The results had not been collated or sent to the CSCI. The Responsible Individual reported that the home only manages the personal monies for one service user. An account of this is kept with accompanying Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 17 receipts. For all other service users, personal monies are managed by the service users representative or by Social Services. There was evidence that staff were receiving supervision, however the records were dated for March 2005. The Registered Manager stated that she had been ensuring this supervision had been taking place, but that there was no overview to evidence this easily. The provision of a matrix for supervision so that a clear record of supervision dates for each member of staff is easily obtainable was discussed and the Registered Manager said she would formulate this. Some servicing and maintenance records were viewed at random. Legionella testing and Gas Landlord Safety certificates were not up to date. Copies of up to date certificates for both findings have since been forwarded to the CSCI. Generic risk assessments were available, as was a fire risk assessment dated 30/07/04, for which there was no evidence that this had been reviewed. Fire drills were recorded as having been undertaken on 14/06/05 and 04/08/05. It was not clear what time of day these drills had been undertaken and whether the night staff were included. Fire alarm tests were being undertaken regularly and weekly health & safety audits are taking place. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 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 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 2 X 2 Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 19 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 2 3 Standard OP7 OP7 OP8 Regulation 13(4) 17(1)(a) 17(1)(a) Requirement Risk assessments for falls must be updated following any falls. The service user plan must be kept up to date. Continence assessments must be formulated for each service user. All assessments must be kept up to date and accurately reflect the service users condition. The risk assessments for bedrails must be comprehensive and identify the appropriateness of the use of bedrails for each individual. These must be kept under review. To continue to update the medicines policy and include procedures for managing refusal of medication and medicines out of the home. When complete there must be a list of approved signature and initials of staff trained to administer medicines. The fridge must be defrosted and the temperature monitored daily to ensure that the temperature is maintained between 2 and 8 degrees centigrade Controlled drug balances must DS0000010955.V269635.R01.S.doc Timescale for action 16/12/05 16/12/05 01/01/06 4 OP8 13(4) 16/12/05 5 OP9 13(2) 01/03/06 6 OP9 13(2) 07/12/05 8 OP9 13(2) 07/12/05 Page 20 Threen House Nursing Home Version 5.0 9 OP9 13(2) 10 OP9 13(2) 11 OP9 13(2) 12 OP9 13(2) 13 OP9 13(2) 14 OP12 16(2)(m) &(n) 15 16 17 OP26 OP29 OP30 13(3) 7,9,19 18 18 OP33 24(2) be accurate and read zero when disposed of. Medicines must be recorded accurately when administered. If not administered the chart must be suitably endorsed and the reason given. Dosage changes must be rewritten on the MAR so that an accurate record of administration is maintained. The home must negotiate and implement a regular cycle of ordering and deliveries of medication so that service users do not run out of their medication and all start a new cycle on the same day each month. Records of receipts and disposals of medication should be available in the home. A current copy must be sent to CSCI for inspection. If the home needs to test the blood glucose of more than one service user then they must purchase a finger pricking device for professional use or use lancing devices such as unistix 2 or safe T pro. 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. Toiletries must not be left in communal areas. Staff records must contain the information required under the Care Homes Regulations 2001. All new care staff must receive induction and foundation training which meets recognised training standards. Results from service users/representatives questionnaires must be DS0000010955.V269635.R01.S.doc 07/12/05 07/12/05 01/02/06 14/12/05 01/12/05 01/01/06 14/12/05 14/12/05 01/01/06 01/01/06 Threen House Nursing Home Version 5.0 Page 21 19 OP38 23(4) 20 OP38 23(4) published, made available to service users, service users representatives and the CSCI. The fire risk assessment must be reviewed annually and whenever there is a relevant change or event in the home. All staff must receive regular fire drill training, including night staff. The times of when a fire drill takes place must be recorded. 14/12/05 14/12/05 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 3 4 5 6 7 Refer to Standard OP3 OP9 OP9 OP9 OP9 OP30 OP36 Good Practice Recommendations The homes pre-admission assessment should be reviewed to ensure that information on all areas of care are included. That the home considers the use of MAR sheets rather than prescription sheets so that non-administration can be recorded more accurately and also stock balances. That the new waste bins for disposal of medication are kept securely in the home and waste sheets are completed for each consignment. That the current finger pricking device is labelled with the service users name That the manager undertakes a regular audit to ensure the accurate recording of medication It is strongly recommended that a matrix be developed evidencing all the training undertaken by the staff. It is strongly recommended that a matrix be developed evidencing the 6 yearly supervision sessions for all care staff. Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection West London Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Threen House Nursing Home DS0000010955.V269635.R01.S.doc Version 5.0 Page 23 - 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!