Inspection on 15/03/07 for Threeways

This inspection was carried out on 15th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 16/01/06

Threeways 18/07/05

Threeways 08/03/05

Threeways 07/09/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Threeways 40 Beacon Road Seaford East Sussex BN25 2LT Lead Inspector Kathy Flynn Key Unannounced Inspection 12:00 15th March 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 Threeways DS0000014068.V324891.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. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Threeways Address 40 Beacon Road Seaford East Sussex BN25 2LT 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) 01323-896196 01323-896196 Mr Bernard Edward Clarke Mrs Caroline Mills, Mrs Barbara Ann Clarke Mrs Shirley Eyles Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability (45) of places Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That the rooms in Firle are available for four (4) service users who require personal care. A maximum number of forty-one (41) service users in receipt of nursing care and four (4) service users in receipt of personal care. Service users must be older people aged sixty-five (65) years or over on admission. Service users with physical disabilities under sixty-five (65) years may be admitted. 16th January 2006 Date of last inspection Brief Description of the Service: Threeways is registered to provide care for 45 residents in total with, nursing care for 41 residents within the categories of older people and physical disabilities and personal support for 4 residents. The home is part of a family business and the owners play an active role in managing and developing the services provided. It is situated in a residential area, close to local amenities and public transport and within walking distance of the seafront and an attractive park. Threeways is on two floors and has been extended to include attractive new rooms with en suite facilities. All resident’s rooms are single and the 4 residents who require personal support have rooms in the older part of the building, Firle House, which is accessed by three steps. A shaft lift enables residents to have access to the rest of the building and the staff use hoists, assisted baths and toilets when providing support for the residents. There are three lounges one in Firle, as well as one on the ground and first floor of the main building, that are used by residents for recreational and social activities. Each of the lounges has a dining area and there is a smaller dining room near the kitchen at the rear of the home. There are attractive gardens to the front and rear of the home that are accessible to wheelchair users and individuals who use walking aids. Threeways DS0000014068.V324891.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 over five hours on the 15th and 21st March. A pre-inspection questionnaire and ten residents surveys were sent to the home prior to the inspection. The completed questionnaire and one survey were returned to the Commission. This inspection included a tour of the home, a review of care plans, preadmission assessments, staff files, training, menus and the activity programme. The nurse in charge, care staff, cook, kitchen staff and activity staff were happy to discuss the care and support they provide for residents. They said that they felt they could meet the needs of residents and the residents spoken with who expressed an opinion were equally positive about the care provided. The reader should be aware that the Care Standards Act 2000 and the Care Homes regulations 2001 use the term service user to describe those living in care home settings. However for the purpose of this report those living at Threeways will be referred to as residents. What the service does well: What has improved since the last inspection? The requirements noted at the last inspection have been addressed. Training in moving and handling is continually reviewed to ensure staff follow the homes policies. Communal rooms are no longer used for staff training. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 6 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 DS0000014068.V324891.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 Threeways DS0000014068.V324891.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): 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are carried out for prospective residents to ensure the home can meet their individual needs. EVIDENCE: Six pre- admission assessments were viewed. They were noted to include information with regard to the medical, nursing and social needs of prospective residents, to enable staff to decide if the home can offer the support and care that they require. The nurse in charge confirmed that they are completed by senior staff at the home, with the involvement of the prospective residents and their relatives. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system is clear and consistent and provides staff with the information they need to satisfactorily meet the residents needs. The staff have a good understanding of the residents support needs. This is clear from the positive relationships which have been formed between the staff and residents. Staff protect residents by following the home policies for medication. EVIDENCE: The care planning system provides staff with a complete picture of the residents individual needs, with relevant risk assessments including moving and handling, falls and nutritional assessments. Daily records are completed and some of the care plans have been reviewed and updated monthly. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 10 However it was noted that some care plans have not been regularly reviewed and there is no evidence that the home addresses the communication needs of some residents. The nurse in charge confirmed that these issues would be discussed with the manager and appropriate action taken. Residents are registered with GP’s and are referred to allied health professionals as required, including Macmillan nurses and dietician. The nurse in charge confirmed that policies and procedures are in place for the ordering, storage and administration of medicines. A set of medicine administration records (MAR) were viewed and found to be completed appropriately. Residents who expresses an opinion said they are very happy at the home and that the staff look after them very well. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a varied programme of in-house activities. The routines of the home are flexible enabling residents to have control over their lives and encouraging them to make choices about all aspects of their day to day living. The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: Two activity staff at the home provide activities for residents from Monday to Friday, in the morning and afternoon. These range from group activities, including games and musical sessions, to taking individual residents out for a walk. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 12 The care plans include a section to record activities for each resident. However these are not completed, therefore it is difficult to identify who takes part in each activity or if the activity programme reflect the preferences and choices or residents. The concern was raised that activities are not provided at weekends and the nurse in charge, and some staff, said that most residents have visitors at weekends so they were not needed. However there was no evidence that any additional support was provided for residents who do not have visitors. Staff spoken with said that they did not have as much time to sit and talk to residents as they would like, although it is quieter in the afternoon they usually have other things to do, like giving out the tea. The nurse in charge confirmed that he would be discussing these issues with the manager and addressing them. Staff spoken with said that the residents are encouraged to regard Threeways as their home, and they are able to make choices about all aspects of their lives, with relatives and friends able to visit at a time that suits the residents. The staff and residents spoken with said the meals at the home are good, they are able to choose what they want for breakfast and supper, and can have an alternative at lunch time if they do not like the main meal. The lunch on the first day of inspection was roast chicken and residents said they ‘enjoyed it very much’. The staff confirmed that drinks and snacks are available at any time. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system with some evidence that residents feel their views are listened to and acted upon. Staff have good knowledge and understanding of Adult Protection issues which protects residents from abuse. EVIDENCE: There have been no complaints about services provided at Threeways, to the home or to the Commission, since the last inspection. The nurse in charge confirmed that appropriate policies and procedures are in place. Training in protecting adults is provided for all staff and those spoken with were able to demonstrate an understanding of abuse and what action they should take if they have any concerns Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing residents with an attractive and homely place to live. Policies and procedures for infection control are in place and training is provided for staff to protect residents. EVIDENCE: Threeways provides a comfortable and homely environment for residents. There are two lounges on the ground floor with a separate dining room, and one lounge on the first floor which is also used by some residents as a dining room. There are attractive gardens to the front and rear that are accessible to wheelchair users, and used when the weather permits. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 15 Residents are encouraged to bring their own possessions with them and many have decorated their rooms with pictures, ornaments and some furniture. Infection control policies are in place and staff have received training in the use of gloves and aprons to protect residents, visitors and staff. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. Robust recruitment procedures are followed to protect residents. Induction training is provided for all new staff to ensure that they are aware of their roles and the support needs of residents. EVIDENCE: The staff spoke very positively about the key worker system, where they are responsible for supporting a group of residents. They felt that they are able to meet their needs and this was supported by residents. Those who expressed an opinion said the staff are able to provide the support the want. The home follows recruitment procedures that require the relevant checks to be made, including two references and Protection of Vulnerable Adults/Criminal Registration Bureau checks. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 17 Appropriate training is provided for staff, including induction training, to ensure they understand the needs of the residents and offer the support they need. Staff are encouraged to work towards National Vocational Qualifications (NVQ) and the home has met the requirement that 50 of care staff should be trained to Level 2 or equivalent. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is well supported by staff in providing clear leadership with staff demonstrating an awareness of their roles and responsibilities when supporting residents. Quality assurance systems are in place to obtain the residents and their relatives comments about the services provided at the home. The health and safety policies and procedures in the home protect residents and staff. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 19 EVIDENCE: The management approach at Threeways is open and inclusive. Residents are encouraged to be involved in developing services at the home, through the quality assurance system and residents meetings. The home does not take responsibility for the finances of residents, they are supported by relatives or other representatives. Training in moving and handling, infection control, fire safety and first aid is provided for staff, those spoken with said they had attended all the training arranged for them. Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 OP33 Regulation 15 12 (1)(2)(3) Requirement Care plans to be reviewed monthly and to include all aspects of the residents assessed needs, including communication. Timescale for action 24/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Threeways DS0000014068.V324891.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Threeways DS0000014068.V324891.R01.S.doc Version 5.2 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. 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