Inspection on 18/07/05 for Threeways

This inspection was carried out on 18th July 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.

Other inspections for this house

Threeways 15/03/07

Threeways 16/01/06

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 Announced 18 July 2005 10.00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Threeways Address Beacon Road Seaford East Sussex BN25 2LT 01323 896196 01323 896196 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr and Mrs Bernard Edward Clarke Mrs Caroline Mills Mrs Shirley Eyles Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (OP) 45 of places Physical disability (PD) 45 Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum number of forty-one (41) in receipt of nursing care and four (4) in receipt of personal care. 2. That the rooms in Firle are available for four (4) service users who require personal care. 3. Residents must be older people aged sixty-five years (65) or over on admission. 4. Residents with physical disabilities under sixty-five years may be admitted. Date of last inspection 8 March 2005 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 residents 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 and one on the ground and first floor of the main building, they are used 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 H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection and the home was informed of the date and time of the inspection several weeks before it was carried out. The requirements from the previous inspection and the information provided in the pre-inspection questionnaire, completed by the manager and the comments cards, completed by the residents and their relatives, were used to plan this inspection. The aims were to assess if the home had met the requirements, identify the aspects of the service that have improved and how the service could be improved for the benefit of residents. The inspection was carried out over five and a half hours from 10.00am and included a tour of the building, an examination of pre-admission assessments, care plans, staff records and policies. There were thirty-three residents in need of nursing care and two residents receiving personal care at the home during the inspection. Ten residents and a visitor were happy to talk about the care and support provided at the home. The deputy manager, administrator, staff and the cook talked about the services they provide for residents. What the service does well: What has improved since the last inspection? The requirements from the previous inspection have been met. Pre-admission assessments of prospective residents are now completed prior to the offer of a room at the home. The care plans now include appropriate information to enable staff to provide care and support. The recruitment procedure has been reviewed and now includes the required checks before prospective employees start work. Records, policies and procedures have been reviewed and updated Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 6 Training in manual handling has been reviewed and updated. The Commission is now notified of any event in the home that may adversely affect the residents. 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 H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5. Standard 6 is not applicable. The homes Statement of Purpose and Service User Guide are good providing residents, prospective residents and their relatives with details of the services the home provides enabling an informed decision about admission to the home. An appropriate pre-admission assessment is used prior to the offer of a room to ensure the home can meet the prospective residents needs. EVIDENCE: The Statement of Purpose and Service Users Guides provides comprehensive information regarding the services offered by the home, it is easy to read and identifies the level of support that the home can provide. Information concerning recent admission were viewed, the pre-admission assessment provides a complete picture of prospective residents needs and these are completed prior to the offer of a room in the home. Prospective residents and their families are encouraged to visit the home to meet staff, residents and to choose a room. Some of the residents explained Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 9 that their relatives visited the home and looked at the rooms before they accepted the room. Residents can move into the home on a trial basis before they decide if they would like to remain as a permanent resident. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10. The care planning system is clear and consistent and provides staff with the information they need to satisfactorily meet residents’ needs. Staff have a good understanding of the residents needs. This is clear from the positive relationships which have been formed between residents and staff. EVIDENCE: The care planning system has been updated all relevant information is provided including risk assessments, Waterlow scores, weights and a daily record of the care and support provided. The care plans are reviewed on a regular basis with the involvement of residents and their relatives. Where appropriate relatives have been contacted in writing and asked if they wish to be involved in the monthly review, the home is waiting for some of these responses. Training has been provided for the trained staff with regard to completing the care plans appropriately and is also discussed during the trained staff’s meeting, on a regular basis. Further training has been arranged with the company that produces the care plan system. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 11 Residents are registered with GP’s and there are links with allied health professionals, including physiotherapists, dieticians and the Tissue Viability Nurse when required. It was noted that the relationship between staff and residents was relaxed and friendly and residents were treated with respect by staff. Residents who expressed an opinion were positive about the care provided by staff, a visitor was equally positive supporting the comments made by residents. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15. Links with the local community are good and support and enrich residents social opportunities. The routines at 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 dietary needs of residents are well catered for, with a balanced and varied selection of food available that meets residents’ tastes, choices and special dietary needs. EVIDENCE: Residents are encouraged to spend their time where they wish, some prefer to stay in their own rooms while others join other residents in the lounges. Two activity co-ordinators provide a varied programme of activities for groups or individuals. During the inspection an entertaining game of shuttle board was enjoyed in the lounge, residents requiring nursing care and personal support took part in this activity. The activity programme also includes visits from outside entertainers and local churches. There is open visiting at the home with relatives and friends able to visit at any time. There were no opportunities to speak to relatives during the inspection, Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 13 however a number of comment cards were received with positive comments about the care provided at the home. Residents are able to exercise personal autonomy and choice if appropriate, some are responsible for their own finances and are encouraged to make choices about all aspects of their lives and are supported if they wish to make changes to their daily routine. Alternatives are offered for all meals, with drinks and snacks available throughout the day. Residents who expressed an opinion were complementary about the food. They said they were given what they asked for, even if they changed their mind and staff offer assistance if required. A meal was enjoyed in the dining room on the first floor with residents who were clearly relaxed and comfortable and happily discussed topics that interested them during the meal. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: These standards were not assessed. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. The standard of the environment within this home is good providing residents with a clean, attractive and homely place to live. EVIDENCE: Threeways provides comfortable, homely, individual and communal space for residents. There are three lounges in the home, a small lounge in Firle House, as well as one on the ground and first floor of the main building. These rooms have dining areas and there is small dining room near the kitchen at the rear of the building that residents choose not to use at the moment. There are attractive gardens to the front and rear that are used by residents and staff when weather permits, on the day of the inspection it was windy and the activity co-ordinator arranged games in the ground floor lounge. There is an ongoing maintenance programme, with regular repairs when required. Building work is continuing in Firle House, the staff room has been re-decorated and a separate lounge is to be provided for their use on the first Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 16 floor. A shower room and separate toilet has been installed on the first floor and the resident’s rooms are to be updated. There are assisted baths and toilets, hoists are available to transfer residents safely and a shaft lift and grab rails enable residents to have access to all parts of the nursing home. Firle House is accessed using steps. There are 45 single rooms in the home, 24 of them have en suite facilities. Furniture, including adjustable beds, tables and chairs, is provided by the home. However residents can bring their own furniture with them with the agreement of the manager. Residents are encouraged to decorate their rooms and many have personalised them with pictures and ornaments. Radiators are guarded and all rooms are naturally ventilated. The home was clean and systems are in place for the control of infection. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 29 & 30 There are sufficient trained and competent staff on duty at all times to meet the assessed care needs of the service users. Thorough recruitment procedures help to ensure the safety and protection of service users. EVIDENCE: In addition to the matron, deputy matron and senior charge nurse, sufficient numbers and an appropriate skill mix of staff ensure that the assessed needs of service users are met. In the morning, there is a minimum of 2 Registered General Nurses (RGN) on duty and 8 nursing auxiliaries. In the afternoon 2 trained nurses work alongside 4 –5 nursing auxiliaries and at night there is 1 RGN and 3 auxiliaries on duty. A recently appointed Nurse Assessor/Trainer has responsibility for all staff training within the home. She confirmed that all new staff receive TOPSS (Skills For Care) induction and foundation training. Many staff also undertake training for NVQ level 2. Mandatory training, including manual handling, first aid and fire safety is provided for all staff on a regular and ongoing basis and is recorded. Recruitment procedures have been reviewed, as required, since the previous inspection. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 18 Documentation relating to the recent selection and recruitment of a nursing auxiliary was examined and found to contain all necessary information, including a fully completed application form, 2 written references and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. It was noted that certain documents currently being used, including the application form and ‘interview from’ were of poor quality, being copies of photocopies. Following discussion, during feedback with the deputy manager and administrator, it is recommended that these forms be reviewed and updated. Members of staff spoken to during the inspection confirmed that they receive and discuss their individual Job Description and consequently are aware of and understand their role and responsibilities within the home. They are also provided with a copy of the ‘Staff Handbook’ and a written contract, detailing their individual terms and conditions of employment. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Service users would benefit from a more structured and formalised system of staff supervision. EVIDENCE: Qualified nurses within the home provide regular supervision for an allocated number of nursing auxiliaries. The deputy manager confirmed that all RGNs are shortly to undertake specific training in staff supervision. A supervision policy has been developed which all staff are expected to read. They also sign a contract, agreeing to the process of formal supervision. Following discussion, it is recommended that the recording format for these supervision sessions be reviewed and amended to include agreed agenda items and any action points carried forward. However it was noted that established RGNs working in the home do not currently receive formal supervision. Nurses spoken to during the inspection Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 20 confirmed that at present all they receive is an annual appraisal of their work, by the matron. Regular meetings provide a form of ‘group supervision and a mutual support structure of one-to-one ‘peer supervision’ is in the process of being developed but is not yet in place. Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score x x x x x x x x 2 x x Threeways H59-H10 S14068 Threeways V229949 180705 stage 04.doc Version 1.30 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 36 Regulation 18 (2) Requirement It is required that all care staff, including trained nurses, receive formal supervision at least six times a year. Timescale for action 31.08.2005 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. Refer to Standard 29 36 Good Practice Recommendations It is recommended that documentation relating to staff recruitment be reviewed and updated. It is recommended that the current recording format for staff supervision be reviewed and amended to include agreed agenda items and action points carried forward. 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