Inspection on 16/01/06 for Threeways

This inspection was carried out on 16th January 2006.

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.

Other inspections for this house

Threeways 15/03/07

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 Beacon Road Seaford East Sussex BN25 2LT Lead Inspector Kathy Flynn Unannounced Inspection 16th January 2006 09:30 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 Threeways DS0000014068.V261567.R01.S.doc Version 5.1 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.V261567.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Threeways Address 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.V261567.R01.S.doc Version 5.1 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. 18th July 2005 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.V261567.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection for the year, and should be read in conjunction with the first inspection that was carried out on 18th July 2005 to give an overview of all the standards assessed within this period. This was an unannounced inspection. The requirement recorded in the previous inspection was used to develop the plan for this inspection. The aim was to assess if the home had met the requirement, identify aspects of the service that have improved and how the service could be developed for the benefit of residents. The reader should be aware that the Care Standards Act 2000 and the Care Homes Regulations 2001 use the terms service user to describe those living in care home settings, for the purpose of this report those living at Threeways will be referred to as residents. The inspection took place over three hours from 09.30, and included an examination of care plans, pre-admission assessments, policies and a tour of the home. There were 41 residents at the home during the inspection, 39 requiring nursing care and two requiring personal support. Twelve residents, a visitor, the chef, the manager and the provider discussed the services provided at the home. What the service does well: What has improved since the last inspection? The requirement from the previous inspection was met and the recommendations have been addressed. Regular supervision is provided for all staff. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 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. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 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.V261567.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: Standards not assessed at this inspection. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 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 the following standard(s): 9 The systems for the administration of medicines are good with clear and comprehensive arrangements in place to ensure resident’s medication needs are met. EVIDENCE: Policies and procedures are in place for the administration, storage and ordering of medicines, with medicine administration charts completed appropriately. There were no residents at the home responsible for their own medication. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 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): EVIDENCE: Standards not assessed at this inspection. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 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 with some evidence that resident’s views are listened to. EVIDENCE: Appropriate complaints procedures and policies are in place. Residents said that they felt able to talk to staff about any concerns they have and the staff try to address them if they can. One complaint had been received by the Commission and was discussed with the manager and provider during the inspection. It had been investigated by the home, as the complainant had contacted them directly, and they were in the process of resolving it. Training in adult protection and abuse is provided for all staff. The manager confirmed that his is part of an ongoing training programme. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 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): 20 The standard of the environment within this home is good providing residents with an attractive and homely place to live. However the lounge on the ground floor is used for staff training at times and therefore residents are unable to use it. EVIDENCE: During the inspection it was noted that the large lounge on the ground floor was being used for staff training. Some residents mentioned that they were unable to use the lounge during the inspection because they had been told that it was needed for training. The use of this room for staff training was discussed at a previous inspection, the manager was advised to seek an alternative venue, and a requirement concerning this is included in this report. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 Page 13 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): EVIDENCE: Standards not assessed at this inspection. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 Page 14 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): 33, 35, 36 and 38 Regular supervision provides support for staff, which enables them to develop the skills and expertise to provide an appropriate level of care for residents. Staff were unable to show sufficient understanding of training in moving and handling, which may put residents at risk. EVIDENCE: A quality audit is completed yearly, it assesses all aspects of the service provided, including the gardens and parking facilities. Residents who expressed an opinion said that they are able to discuss the care they receive, are able to say what they think and feel the staff listen. The home does not accept responsibility for resident’s finances. Where appropriate residents manage their own money or have the support of relatives or solicitors. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 Page 15 The manager confirmed that supervision is in place for all staff on a regular basis. Study days were arranged to ensure that the staff have a good understanding of the purpose of supervision and are able to offer appropriate support. Training is provided for all staff, including those required by legislation. Discussion regarding moving and handling training highlighted confusion concerning the use of some aids, additional training is required to ensure that safe and correct procedures are followed. Threeways DS0000014068.V261567.R01.S.doc Version 5.1 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X 2 X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 3 X 2 Threeways DS0000014068.V261567.R01.S.doc Version 5.1 Page 17 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 OP20 Regulation 23(2)(h) Requirement The use of communal rooms for staff training to be reviewed and alternative accommodation sought, which will enable residents to use the lounges if they wish. Moving and handling training to be reviewed and update to ensure that all staff have a clear understanding of the training requirements. Timescale for action 13/02/06 2 OP38 13(5) 13/02/06 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.V261567.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Threeways DS0000014068.V261567.R01.S.doc Version 5.1 Page 19 - 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. 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