Inspection on 10/07/08 for Whitefriars Nursing and Residential Home

This is the latest available inspection report for this service, carried out on 10th July 2008.

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

Whitefriars Nursing and... 18/07/06

Whitefriars Nursing and... 03/10/05

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/11/2008.

CARE HOMES FOR OLDER PEOPLE Whitefriars Nursing and Residential Home 9 Dormers Wells Lane Southall Middlesex UB1 3HU Lead Inspector Ms Jean Bovell Unannounced Inspection 10th July 2008 10:30 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 Whitefriars Nursing and Residential Home DS0000064702.V366502.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. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitefriars Nursing and Residential Home Address 9 Dormers Wells Lane Southall Middlesex UB1 3HU Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8574 0156 020 8574 1487 whitefriarsnursinghome@yahoo.co.uk Caring Consultancy Ltd Manager post vacant Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate service users who are medically or chronically sick over the age of 40 years. As agreed on 21st February 2006, one named service user with Dementia can be accommodated within the home. This is approved for as long as there is no deterioration of the service user that affects the well-being of any other person living at the home. The home must advise CSCI when the service user no longer resides at the home. 20th September 2007 Date of last inspection Brief Description of the Service: Whitefriars is a nursing home registered to provide care for twenty-eight service users. It is privately owned and the Registered Provider is Caring Consultancy Limited. The home is a detached house located within a mile of Southall Broadway and is accessible to shops and public transport links. There is parking in front of the home and on the main road. There are eighteen single bedrooms and five double bedrooms situated over two floors. There is a large lounge with access to a patio and enclosed attractive rear garden. The dining room looks out onto the front garden. Staff employed at the home includes registered nurses, care assistants and ancillary workers. The fees are currently between £475 and £800 weekly. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is TWO STAR this means the people who use the service experience GOOD quality outcomes. This inspection was carried out between 10:30am and 4:30 pm on 10th July 2008. The Registered Provider, Manager Designate, two Registered General Nurses, five care assistants and 21 residents were at the home. During the course of the inspection, the home’s records, documents, policies and procedures were viewed. A tour of the building was undertaken and observations were made. One Registered General Nurse, three care assistants, the activities coordinator, the cook and eight residents were spoken with. A completed Annual Quality Assurance Assessment – self assessment document was considered. The requirements that were made at the last inspection and all key Standards were examined. The Registered Provider and Manager Designate provided appropriate assistance throughout the inspection. What the service does well: The home provides a service to people of different cultural, religious and linguistic needs. This is reflected in the diverse staff group. The separate needs of prospective residents are fully assessed prior to admission. The separate healthcare needs of residents are regularly assessed and met as needed. Prescribed medication and home remedies are properly managed. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 6 Residents are able to participate in regular activities organised by the home’s Activities Co-ordinator. A variety of nutritious and appealing meals which includes cultural choices are provided and residents confirmed that they received enjoyable meal options. All records viewed were satisfactory and indicated that the health and safety of residents were being safeguarded. Residents were appropriately dressed and appeared comfortable and content. They related in a friendly manner with care staff and those spoken with expressed satisfaction with the care and support they received. Overall, the home was clean, hygienic and reasonably well maintained. The environment was safe, calm and homely. What has improved since the last inspection? What they could do better: Risk assessments must be carried out in relation to specific activities identified within all care plans. Regulation 37 forms must be completed and submitted to the CSCI, where appropriate. Dementia training must be delivered to ensure that care staff are competent in meeting the needs of all the people who receive a service. Please contact the provider for advice of actions taken in response to this Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 7 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. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 8 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 Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 9 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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are comprehensively assessed prior to admission. The home does not currently provide an intermediate care service. EVIDENCE: The personal files of six residents were inspected at random. It was evidenced that a written assessment had been submitted to the home by the placing authority at the point of referral. A subsequent needs led assessment was carried out by home and initiated with a visit to the prospective resident. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 10 Social workers, relevant healthcare professionals, relatives and prospective residents were involved in the process of assessing and determining the capacity of the home to meet separate identified needs. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 11 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 changing needs of residents are reflected in their separate care plans and are being met satisfactorily. None of the residents self administer their medication. Policies on privacy and dignity are in place and people are being treated with respect. EVIDENCE: Residents’ care plans were inspected at random and reflected that their individual and changing personal, healthcare, nutrition, mobility and social needs were identified and action plans and goals were put into place. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 12 All care plans viewed were regularly reviewed. The records were indicative of people receiving access to healthcare professionals as needed and were accompanied to medical appointments. We were informed by the Manager Designate that a General Practitioner and a Physiotherapist visited the home each week. The Chiropodist, Dentist and Optician visited annually and/or when required. We were informed by a registered nurse that none of the residents had developed pressure sores and that pressure mattresses and cushions were being used. Prescribed medicines and home remedies were appropriately stored. Records were maintained of medication received and returned to the Pharmacist. Medication administration records were accurately documented and signed. Prescribed medication and home remedies were administered by registered nurses. We were informed by a registered nurse that people who received a service lacked capacity to self administer their medication. Care staff were observed relating to residents in a respectful manner and people that were spoken with reported that their privacy and dignity were respected. Policies and procedures on medication were in place. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 13 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. People are able to participate in different cultural, social and religious activities. Contact with relatives and/or friends are encouraged and facilitated. People are supported in exercising choice in relation to their daily living routines. Varied and nutritious meals including cultural choices are being provided. EVIDENCE: The social, cultural and religious needs of residents were identified in their separate care plans. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 14 The Manager Designate confirmed that religious festivals such as Eid, Diwali and Christmas were celebrated and that clerics from a Christian denomination visited the home each month. The home has an activities co-ordinator and the records indicated that weekly activities included ball games, music and movement, hand massages, foot therapy and bingo. Entertainment was provided by a visiting singer/pianist every six weeks. Residents spoken with confirmed participating in activities at the home and being recently taken to a pub lunch. They were observed playing board, card, and ball games, watching television, listening to music and reading in the main lounge, and being involved in individual activity in the dining room. Others rested or listened to music of cultural choice in individual bedrooms. One person went unaccompanied to a shopping trip within the local community. An open visiting policy was in place and people reported receiving visits from their respective relatives and/or friends. A visitor was seen being welcomed to the home at the time of the inspection. People received choice in relation to their daily living routines such as when they got up on mornings/retired at night, meals, activities and personal purchases. They were able to remain and have meals delivered to their bedrooms, join others in the lounge/dining room or be involved in separate activity in the dining room or garden. Residents with capacity were able to handle their own money, be independent in the community and prepare specific culturally preferred meals. A resident received a late/cooked breakfast at the time of the inspection and individual choice was also reflected in the way people were dressed, hairstyles and personalised bedrooms. A senior and a weekend cook were employed at the home. An abundance of fresh, dried and frozen food was in store and menus were reflective of nutritious meals including cultural varieties being provided. Drinks and snacks were offered at set times between meals. Wholesome and appealing lunch options were served at the time of the inspection and everyone spoken with expressed satisfaction with the meals they received. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 15 Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 16 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 complaints procedure is satisfactory and people are being protected from abuse. EVIDENCE: The complaints procedure was clearly detailed and accessible to residents and visitors. There was recorded evidence that complaints made to the home were appropriately investigated and the Safeguarding Adults Team was informed of incidents, where appropriate. Allegations regarding general poor standards at the home and in particular practice associated with a named resident were made to the CSCI by a relative. These allegations were investigated by the Safeguarding Adults Team but safeguarding issues were not identified. Agreed action in resolving the matter was in progress at the time of the inspection. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 17 Accidents and incidents sustained by residents were being recorded. We were informed by the Registered Provider that relatives or placing authorities held responsibility for the financial affairs of the majority of residents and others handled their own money. Personal cash was not held in safekeeping on people’s behalf. Policies and procedures on the protection of vulnerable adults were in place and records were reflective of staff training on Safeguarding Adults being delivered. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 18 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, 23, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being adequately maintained. The environment is safe, calm and homely. EVIDENCE: Communal areas on the ground floor are spacious, comfortably furnished and suitable for shared and individual activity. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 19 A programme of redecoration and refurbishment was in place and the scheduled work had commenced and was ongoing at the time of the inspection. The garden is accessible to residents and was maintained. Issues regarding the laundry were not identified. Bedrooms were suitably furnished and fitted, and reflected personal interests and choices. Overall, the home was clean, hygienic and adequately maintained. The environment was safe, calm and homely. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 20 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 is good . This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are adequate. Care staff members have received training and are qualified for meeting the needs of residents but dementia training has not been delivered. Recruitment procedures are satisfactory. EVIDENCE: It was indicated on the completed Annual Quality Assessment (AQAA) that a total of twenty care staff was employed at the home. The Manager Designate confirmed that of these, six were registered nurses. There was also an activities co-ordinator. Ancillary staff include a main cook who prepares meals on week days and holds overall responsibility for the running of the kitchen. A weekend cook, a laundry assistant and one domestic. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 21 The rota indicated that two nurses and five care assistants were on duty during waking hours and one nurse and two care assistants covered waking duty at night. Records were reflective of induction training being delivered to new care staff. Up-to-date staff training included Male Catherisation, Tissue Viability, Incontinence and Physical Disability. It was not evidenced that care staff had received training in dementia. We were informed by the Manager Designate that seven care assistants had achieved NVQ level 2 and six care assistants were completing NVQ level 3. Care assistants and registered nurses were observed being competent in meeting the needs of residents. People that were spoken with confirmed that they were at all times supervised in the main lounge and their needs were being met satisfactorily. Six recruitment files were viewed at random. Each file contained all documents required under schedule 2 of the care homes regulations 2001. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 22 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 Designate is suitably qualified and experienced. Annual quality assurance has been undertaken satisfactorily. The home is not involved in the financial affairs of residents. Risk assessments have not been carried out in all cases and regulation 37 forms are not being completed and submitted to the CSCI. EVIDENCE: Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 23 The Manager Designate was appointed in February 2008 and is in the process of being registered. The Manager Designate confirmed that she was a registered nurse who held a Management Diploma and had eleven years managerial experience. Registered nurses and care assistants spoken with reported that the Manager Designate was approachable and supportive. She was observed interacting in a friendly manner with care staff and residents. An Annual Quality Assurance Assessment document (AQAA) was completed and returned to the CSCI at the required time. What the home did well and areas requiring improvements were identified. Numerical information was also provided. The home does not carry any responsibility for people’s financial affairs. All health and safety checks including those carried out in relation to water temperature, fire safety, portable appliances and gas maintenance were up-todate. Tests for legionella had been undertaken. Fire drills were carried out on a monthly basis. Environmental risk assessments were in place but risk assessments had not been carried out in relation to activities identified within care plans in two of six files viewed. Incidents and accidents sustained by residents were recorded but regulation 37 forms were not completed and submitted to the CSCI as required. There was documented evidence that staff training and/or refreshers delivered included Moving and Handling, Infection Control, Health and Safety and Food Hygiene. Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 24 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 3 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 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 2 Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 25 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 OP30 Regulation 18(1)(C) (I) Requirement The Registered Person must make sure that training on dementia is delivered to care staff to ensure competency in meeting the needs of all the people who receive a service. The Registered must ensure that Regulation 37 forms, where appropriate, are completed and faxed to the CSCI in relation to incidents and accidents. The Registered Person must ensure that risk assessments are carried in relation to activities identified within all care plans to avoid unnecessary risks to the health and safety of residents. Timescale for action 30/11/08 2. OP37 37(1)(c) (d)(e) 30/07/08 3. OP38 13(b)(c) 30/07/08 Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 26 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 Whitefriars Nursing and Residential Home DS0000064702.V366502.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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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