Inspection on 14/02/07 for Threeways

This inspection was carried out on 14th February 2007.

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.

Other inspections for this house

Threeways 18/09/07

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

CARE HOME ADULTS 18-65 Threeways Threeways Care Home 5 Brighton Road Salfords Surrey RH15BS Lead Inspector Denise Debieux Unannounced Inspection 14th February 2007 10:00 Threeways DS0000068365.V327591.R01.S.doc Version 5.2 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 Threeways DS0000068365.V327591.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 Adults 18-65. 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. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Threeways Address Threeways Care Home 5 Brighton Road Salfords Surrey RH15BS 07900 088269 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) Mr T Purmah & Mrs B M Purmah Tecknarainsingh Purmah, Mrs Bibi Mimma Purmah Tecknarainsingh Purmah Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection N/A Brief Description of the Service: Threeways Care Home is registered to provide care and accommodation to six service users with a learning disability. The home is a 2 storey, detached house, set in it’s own grounds in Salfords, near the town of Reigate, Surrey. There are four bedrooms on the ground floor and two on the first floor. All bedrooms are single occupancy, with four having en-suite bathrooms, one having an en-suite toilet and wash hand basin and one having a wash hand basin sited in the room. There is an additional bathroom with an assisted bath on the ground floor. The ground floor provides a communal lounge/dining room, a kitchen and facilities for laundry. There are garden areas to the rear and the front of the property with ample room for parking at the front of the home. Although the home is not operational at present, the provider estimates that fees will range from £1500-£2500 per week, based on individual costings of the service user’s individual needs. This fee will not include activities such as: cinema, theatres, swimming etc., transport, hairdressing, toiletries, dry cleaning, magazines and papers. The fee may include the provision of a yearly, seven day holiday but will be dependant on individual funding arrangements. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place over four hours and was carried out by Denise Débieux, Regulation Inspector. The visit formed part of the first key inspection since Threeways Care Home was registered in September 2006. At present the home is non-operational, i.e. no service users have been admitted or staff employed. The inspection was therefore verbally announced prior to the visit to ensure that the registered provider would be available to provide access and an update on developments since registration. The registered provider is also the registered manager for the service. As there are no service users at present, it has not been possible to assess the outcomes for service users. The quality judgements in this report have therefore been based on limited evidence obtained by looking at proposed documentation, the policies and procedures in place, touring the home and by discussions with the provider/manager. Until there are service users living at the home it will not be possible to evaluate the outcomes for service users, for this reason the maximum quality judgement within each outcome group can be no higher than ‘adequate’. 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. The summary of this inspection report can be made available in other formats on request. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Until the home is operational it will not be possible to make a judgement that is based on the outcomes for service users. Policies and procedures are in place to ensure that prospective service users’ individual aspirations and needs will be assessed, prior to being offered a place at the home. EVIDENCE: The procedure for assessing prospective service users was discussed at this visit. The provider stated that, following an enquiry he will take initial details to ensure that the prospective service user falls within the home’s category of registration. Following this the service user will be visited by the provider and a comprehensive pre-admission form will be completed, with information being sought from the service users, their relatives, current carers and any other involved health and social care professionals. This information will be used to begin drawing up a detailed care plan and carrying out risk assessments. If it is felt that the home can meet the service users’ assessed needs, the service user will then be invited for a series of visits. The first visit will be for a few hours to view the building, meet the service users and staff and to have a meal at the home. A second visit will then be arranged for the whole day, followed by a third visit for an overnight or weekend stay. Where possible the Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 8 provider stated that he would try to arrange for staff from the home to go to work with the prospective service user for a few hours wherever they are residing prior to moving to the home. As well as forming part of the ongoing pre-admission assessment process, these visits will be used to observe the interactions between the prospective service user and the other people at the home. The views of staff and other service users will be sought following each visit. If these visits all go well the home will then arrange a ‘transitions’ meeting, involving the prospective service user, their relatives/representatives and care manager. If it is decided that the home can meet the prospective service user’s needs, and the service user wishes to proceed, a place will be offered on the basis of a six-week trial period. Although not assessed during this visit, the provider was aware of the recent changes to legislation requiring additional information to be included in the home’s service users’ guide and is in the process of updating this document. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Until the home is operational it will not be possible to make a judgement that is based on the outcomes for service users. Policies and procedures are in place to ensure that future service users’ individual plans will include details of their personal needs and goals, incorporating known or indicated preferences and choices, and including in depth risk assessments. EVIDENCE: The procedure for planning and maintaining future service user’s care was discussed at this visit and the care planning documentation was seen by the inspector. The provider stated that, following the initial pre-admission assessment and together with the service user, he will begin to draw up a care plan to include the service user’s likes and preferences and also detailed risk assessments for any identified risks. This care plan will then be discussed and agreed at the ‘transition’ meeting, prior to the service user being offered a place at Threeways. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 10 The provider plans that the care plan will then be added to and further developed during the prospective service user’s six week trial period. The home plans to review care plans on an ongoing basis, with formal reviews after the initial six weeks of placement, then at three months, six months, one year and then yearly thereafter or should a service user’s needs change. The care plan documents seen included all areas of a service user’s health, personal and social care needs and assessment forms for associated risks. The provider plans to use a ‘person centred’ approach to care planning. The provider also stated that any equality and diversity needs will be discussed and assessed in the pre-admission stage and any needs identified will be incorporated into the service user’s care plan. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Until the home is operational it will not be possible to make a judgement that is based on the outcomes for service users. Arrangements are in place to ensure that future service users will have opportunities to take part in appropriate activities within the home and in the local community. The provider stated a commitment to supporting service users in maintaining and developing appropriate personal and family relationships. Arrangements are also in place to ensure that meals provided will be well-balanced and varied. EVIDENCE: The provider stated that links have already been established with local colleges and day centres. The local day centre also has a career’s advice and recruitment person who will be able to help service users find appropriate employment in the local area, should they wish. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 12 The home plans to support and enable service users to utilise local community facilities such as riding school, hydro pool, library, shops, restaurants, theatres and cinemas etc. Once service users are admitted, the provider stated that activities will be developed with each individual service user, based on their individual interests. The provider has developed a set menu, following nutritional advice, that will be used in the very early stages after the first service users are admitted. However, the home plans to move to the service users and staff planning menus together as soon as possible and following appropriate training. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Until the home is operational it will not be possible to make a judgement that is based on the outcomes for service users. Policies and procedures are in place to ensure that future service users’ physical and emotional health needs will be met and that they will receive personal support and care in the way they prefer and require. Policies and procedures are in place for the administration and management of medications. EVIDENCE: As stated earlier in this report, the proposed care planning system will include individual service user’s preferences in how care is delivered and will incorporate their physical and emotional needs. The provider has obtained a copy of the Royal Pharmaceutical Society’s guidelines for the administration and handling of medications in care homes. All staff will be required to follow these guidelines and only staff that have received appropriate training will deal with medications. There is a lockable medication cabinet in the staff room and the provider plans to use a ‘blister pack’ system of medication provided by a local pharmacy. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Until the home is operational it will not be possible to make a judgement that is based on the outcomes for service users. Policies and procedures are in place to ensure that future service users will feel that their views will be listened to and that they will be safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: The home has a complaint’s procedure that contains timescales and is also available in picture format. The provider stated that all service users and their representatives will be given a copy with the home’s pre-admission information. The provider is aware of the local Surrey Multi-agency Procedure for the Protection of Vulnerable Adults (POVA) and a copy is available at the home, as is a copy of the latest POVA guidance from the Department of Health. The provider stated that POVA training is included in their induction programme for all staff. Some minor amendments are needed to the home’s complaints procedure in order to comply with the standards and regulations and the provider is in the process of revising the home’s POVA policy to bring it in line with the Surrey procedure. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Until the home is operational it will not be possible to make a judgement that is based on the outcomes for service users. The home has the facilities to offer a good standard of accommodation to future service users. EVIDENCE: There are four bedrooms on the ground floor and two on the first floor. All bedrooms are single occupancy, with four having en-suite bathrooms, one having an en-suite toilet and wash hand basin and one having a wash hand basin sited in the room. There is an additional bathroom with an assisted bath on the ground floor. The ground floor provides a communal lounge/dining room, a kitchen and facilities for laundry. There are garden areas to the rear and the front of the property with ample room for parking at the front of the home. Ramps have been provided to enable disabled access to the ground floor. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 16 The provider plans to provide wireless connections at the home should service users wish internet access in their rooms and the provider is in the process of having television aerial points fitted in the bedrooms. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Until the home is operational it will not be possible to make a judgement that is based on the outcomes for service users. Policies and procedures are in place to ensure that future service users will be supported by competent and qualified staff and that future staff will be employed only following a robust recruitment process. EVIDENCE: At present the registered provider, who is also the registered manager, is the only member of staff, no other staff members have been recruited. The provider is aware of the amended staff recruitment and supervision regulations and has a copy of the CSCI recent publication ‘Safe and Sound’ on staff recruitment. The provider has copies of the new, mandatory, Skills for Care induction standards, which the home will use for all new staff induction training. The provider stated that all staff will be required to enrol on National Vocational Qualification (NVQ) level 2 training following the successful completion of their probationary period. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 18 The provider has already sourced and established a link with an external training company to provide all statutory health and safety training. The inspector was advised that additional training will be provided to all staff, dependant on the needs of individual service users and the tasks that staff will be expected to undertake. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Until the home is operational it will not be possible to make a judgement that is based on the outcomes for service users. The registered provider expressed a commitment to establishing and running a care home providing high standards of care to future service users. Policies and procedures are in place to ensure that the health, safety and welfare of future service users and staff will be promoted and protected. EVIDENCE: The provider/manager has been qualified as a registered nurse (mental health) for the past seven years. Since that time he has worked at NHS hospitals and has also gained experience working with people with learning disabilities in registered care homes. In 2003 he obtained an additional qualification of BSc in healthcare and is currently undertaking his Registered Manager’s Award, which he expects to complete by the end of this year. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 20 The home has a quality assurance and monitoring system, based on seeking the views of service users, that will be implemented when the home is operational. Health and safety policies and procedures are in place and were sampled during this visit, the provider will be the designated health and safety person for the home. The inspector was advised that, as the home hopes to begin recruiting staff and admitting service users in the near future, the provider plans to carry out a final check of all policies and procedures against the National Minimum Standards and Regulations and carry out environmental health and safety risk assessments prior to the home becoming operational. Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 2 X Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Threeways DS0000068365.V327591.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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