Inspection on 06/07/05 for Whitebirch Lodge

This inspection was carried out on 6th July 2005.

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

Whitebirch Lodge 06/08/07

Whitebirch Lodge 29/11/06

Whitebirch Lodge 05/02/06

Whitebirch Lodge 07/10/04

Whitebirch Lodge 07/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Whitebirch Lodge 104 Canterbury Road Herne Bay Kent CT6 5SE Lead Inspector Kim Rogers Announced 06/07/05 at 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. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Whitebirch Lodge Address 104 Canterbury Road, Herne Bay, Kent, CT6 5SE 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) 01227 374633 01227 360620 hernebay@homeservice.uk.com Krystlegate Limited Mrs Marilyn Squire Registered Care Home 17 Category(ies) of Older People x 17 registration, with number of places Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home provides personal care and support to 17 older people. No other conditions apply. Date of last inspection 7/10/04 Brief Description of the Service: White birch Lodge is a detached three-storey building that has been extended to include the ground floor accommodation in the adjoining property; also owned by Mr and Mrs Squire. The Home provides personal care and support to 17 older people who are over 65.Service Users are accommodated on the ground and first floors and a stair lift provides access to the first level. There are 17 single bedrooms, all of which have en suite WC facilities. All rooms are fitted with a television aerial point, a telephone point and an emergency alarm call point.The Home is situated in a seaside town within easy reach of shops, public amenities and transport. The rear garden is secluded and attractive. The front area of the Home provides off street parking. Staff are on duty 24 hours a day and senior staff on-call can be contacted for advice. Mr. Paul Knight is currently Acting Manager. Mr. Knight has over two years experience in managing a care home and has completed the necessary qualification for a Manager.Mr. Knight will be applying to Commision to register as the Manager as Mr. Squire has now retired. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and carried out by Kim Rogers from 10.00 to 16.00 on a Wednesday. The Inspector spoke to Service users in private and as a group. There are currently 16 service users living at this home. The Inspector met with the Acting Manager and 2 senior staff and spoke to other staff. The Inspector looked at some records and looked around the home. The home submitted a pre inspection questionnaire with supporting documentation which the Inspector looked at in detail and discussed with the Acting Manager. The home has shown commitment to meeting the National Minimum Standards. The requirements and recommendations form the last inspection have all been met. Staff made positive comments about working at the home and Service users made positive comments about living at the home. The Inspector spoke to one Service who had just moved in. The Inspector looked at the records relating to this person. All were detailed and in order. The owners have invested in the premises. The home is maintained to a high standard which includes the furniture and décor. Service users said this home is always ‘spotless’. The Inspector observed lunch being served. Service users said the ‘food is good ‘and that fresh vegetables are always served’. One Service users said ‘the cook is great’ All of the Service users spoken to said that their needs are being met. One Service user said she was woken too early in the morning on one occasion; this was discussed with the Acting manager and senior staff. The Inspector was assured that Service users get up in their own time and if this did happen it would not happen again. The pace of life at the home during this visit was relaxed and happy. Service users were calm and happy were making choices about how to spend their day. Service users told the inspector that staff are kind and respect their dignity and privacy. The home plans to move the office to outside to enable development of three further en suite bedrooms. The Acting Manager will keep the Commission informed of the plans for this. The Inspector concluded that this home provides a good standard of care and support to Service users. What the service does well: The staff team is long standing and experienced. Staff were observed supporting Service users in a discreet respectful manner. Staff, senior staff and Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 6 the Acting Manager spoke with knowledge and understanding of Service users needs. The staff team is long standing and multi skilled leading to good quality consistent care. The home has access to a training Manager who facilitates regular courses. The décor and furnishing and fittings are of a very good standard. The home has a very homely feel. Carpets and furnishings are of good quality. The home is clean. Service users said their rooms and the home are always ‘spotlessly clean’ The home exceeds some of the minimum standards relating to the environment. Documentation and records are well organised and regularly reviewed. Policies and procedures are available and regularly reviewed. Staff have knowledge of these policies and procedures. The experienced senior staff, the owners and the Manager of another branch of the business support the Acting Manager. Communication between the acting Manager, senior staff and staff team is good. The home employs a team of cleaners who keep the home very clean. An experienced cook provides wholesome and nutritious meals to Service users. Service users said the ‘staff are caring and kind’ One service user a member of night staff ‘is an angel’ one Service user said ‘they couldn’t do more for you’ and ‘I cannot fault the staff’ What has improved since the last inspection? What they could do better: Service user plans and detailed and regularly reviewed. The Inspector noted that there was limited detail about one Service users background. Some guidelines for another Service user were not very detailed. The Acting Manager Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 7 agreed to address this be reviewing all plans to ensure information is detailed and up to date. The Inspector noted that during a test of the fire alarm some fire doors did not close properly. The acting Manager agreed to address this at once. There was no record of medication entering the home. The senior staff agreed to start recording this on the medication administration records. The acting Manager agreed to remove bar soap and replace it with liquid soap, which is more hygienic. The home falls short of the standard of 50 of staff qualified to level 2 NVQ having about 25 qualified. The Acting Manager said that the home has gained some funding for some staff to start the award. All staff have Criminal Records Bureau checks on file apart from 2 domestic staff under 18 years of age. The Inspector recommended that these checks be carried out to protect Service users. 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. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Service users are given thorough information about the home to help them make a decision about moving in. Service users know that they can have a trial stay before they make a final decision. Service users are aware of the terms and conditions of their stay. Service users know their needs will be fully assessed and that this home meets their needs. EVIDENCE: The home has a detailed Statement of Purpose and Service user guide. The standards detail what is to be included. The purpose of these documents is to give prospective Service users and their representatives the information they need to make a decision about the home. The home has the information required which is reviewed regularly. A new Service user to the home said she was given some information about the home and was able to visit and have a trial stay before making a decision about moving in permanently. The acting Manager said that information is sent or given to people enquiring about Whitebirch Lodge. The home has sent copies of the statement of purpose and Service user Guide to the Commission as required. The home also gives prospective Service users copies of their policies and procedures. Service users Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 10 sign to say they have received these. The Inspector saw these signed sheets in service user plans. All service users are issued with a statement or contract of conditions of their stay. Contracts were seen in Service users files. A representative of the home and the Service user or their representative had signed all contracts seen. These contracts are held securely in the office and included all of the required information. A Service user has moved in to the home recently. The Inspector saw a copy of the Care Management assessment for this Service user. There was also a pre admission checklist completed by the home and dated the day of admission to the home. The full range of needs under the standard was assessed. The standards identify this function to be essential to the proper management of residential care provision and the management of any potential risks to service user health and safety. The assessment forms the basis of the Service User plan. The Acting Manager, Service user and their family as well as senior staff had been involved in the assessment. The home carries out detailed assessments to ensure that it can meet a persons needs. All of the Service users spoken to said that their needs are being met. The staff team are long standing and experienced and spoke with knowledge of Service users needs. One staff spoken to had only been in post for a few months. This staff spoke with empathy and understanding. Staff were observed supporting Service users respectfully and discreetly. The home works with health care professionals to ensure the home can meet any changing needs. The Acting Manager said that prospective Service users could visit the home before they make a decision abut moving in. One Service user new to the home confirmed this. She said that she had visited with her family any made overnight stays before deciding to move in permanently. A review is held after about one month to ensure the Service user is happy before the placement is made permanent. This home does not generally offer a respite care service. The Manager said that this was only available if and when there was a spare room. The fees for this home are £295.85 to £380 per week. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Service Service Service Service users users users users know their needs will be met. health care needs are met. are protected by the homes medication procedures. know they will be treated with respect. EVIDENCE: The Inspector sampled a number of Service user plans (care plans) then met the Service users concerned and cross referenced the information. Service user plans are developed from the assessments carried out by the home. These plans are generally well detailed with the persons needs recorded with actions staff should take to meet the person’s needs. The Inspector noted that the plans are reviewed regularly by senior staff and again in detail on a six monthly basis. This ensures that any change in need is identified and recorded. The Inspector read one then spoke wit the Service user who told the Inspector about their early life growing up in south London. This information was not included in the Service user plan; there was little background history. One Service user can have verbal outbursts. Staff talked about how they support this person using distraction tactics however not all of this useful information was recorded in the Service user plan. The Manager agreed to address this. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 12 Service users and their relatives are involved in developing these plans and had signed them to say they agree. Personal care needs and health needs are recorded with actions by staff to meet these needs. All Service users are registered with a GP. Some have support from the district nursing team. Staff told the inspector about when and how they would seek further medical advice. It was evident that Service users have regular checks with health care professionals. Potential risks relating to Service users health are assessed and recorded in Service user plans. Staff then follow strategies to reduce and where possible eliminate risks. A visiting professional offers armchair exercise classes. Service users said they enjoy these sessions of gentle exercise. Diet and nutrition is monitored. The Inspector concluded that service users have access to a full range of medical and health care support. The Inspector spoke to the senior staff about medication procedures. Staff told the Inspector in detail about how they receive, administer and dispose of medicines. Staff administer in line with the Royal Pharmaceutical Society Guidelines. The home has a secure medication trolley and a medication cupboard for extra storage. No service user at this home self medicates. This decision is made by all included at the assessment stage. Staff attend training and are shadowed and observed by senior staff before they are deemed competent to administer medication. Staff have access to reference material about medicines. The Inspector looked and medication administration records, (MAR) These were well recorded with staff only signing when a person has taken their medication. The Inspector noted that there was no record of medicines coming into the home. The senior staff agreed to start recording this on the MAR. Medication was discussed further with the senior staff and the Acting Manager. The staff have ideas about improving medication systems. Currently a weekly supply is delivered in Dossette boxes. Staff felt a monthly supply may be more suitable. The Acting Manager said he would look into this further. Service users see their GP’s for regular medication reviews. Service users told the Inspector that staff always knock on their doors before entering and that staff are respectful. One Service user said that staff are aware of her privacy and dignity when supporting with personal care. Treating people with respect is included in the staff induction. Service users preferred term of address is recorded in Service user plans. Service users are able to have private telephones in their rooms. One Service user who has recently moved in said she was grateful for the phone as she can keep in touch with her family and friends. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Service users know the lifestyle with suit them. Service users have contact with friends and family. Service users have support to make choices and exercise control. Service users know they will have good quality nutritious meals served in pleasant surroundings. EVIDENCE: The Inspector observed that the pace of life at the Home was relaxed and unhurried. Service Users confirmed this saying they could ‘ do things in their own time’. Service Users told the Inspector about activities offered by the Home. One Service user ‘ there is a lot going on’ They said that a duo continue to visit the Home on a monthly basis who consist of a man playing a keyboard who accompanies a female singer. Service Users said that this was popular as the duo play and sing the ‘old songs’. Service Users said they enjoyed this. The Inspector was told that a volunteer visits the Home on a weekly basis on Thursdays and facilitates a cards and dominoes afternoon. Service Users said they enjoy this, some said they choose not to attend. Bingo sessions are held regularly as well as armchair fitness sessions. Service Users said the activities offered by the Home suit their needs. Preferences about activities are recorded in Service User plans. After speaking to Service Users and staff the Inspector concluded that the Home offers an adequate range of activities. The Inspector Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 14 observed staff organising an activity for a Service User who appeared anxious. The staff used their knowledge of the Service User to provide a suitable relaxing activity in a discreet appropriate manner. The Inspector saw that Service Users views about the activities on offer at the Home are ascertained using the quality assurance questionnaire. Service users told the Inspector that they have visitors at reasonable times. Service users said that they could see visitors in their rooms or in one of the lounges. The Home’s arrangements for supporting and maintaining links with families and friends are detailed in the Home’s Statement of Purpose and Service User Guide. Staff confirmed that visitors are welcome at reasonable times. The visitor’s book showed that there are regular visitors to the home. The Inspector spoke to one Service user in her room. This Service user was expecting a visitor that afternoon. Service Users were dressed in their own clothes and had individual styles. Service Users said they choose how to spend their day and make choices about the meals offered. Staff said that Service users are able to bring their own personal possessions into the Home. Service users confirmed this. The home employs a full time qualified cook. Service users likes and dislikes are established at the assessment stage. The cook follows a rolling menu planned after consultation with Service users. Alternatives are provided if a Service user does not like the first choice. The dining room is attractive with tables laid with tablecloths, flowers and placemats. Service users said they could choose to eat in their rooms if they wish. The Inspector observed staff supporting Service users where necessary in a discreet respectful manner. The pace at lunchtime was relaxed and unhurried. Service users made positive comments about the food at the home. One Service user ‘the cook is great’ ‘the food is very good, we always have fresh vegetables and second helpings’ On the day of the inspection fresh meat and vegetables were served with a hot pudding. Snacks and drinks are served throughout the day. This home caters for special diets. After talking to Service users and staff the Inspector concluded that this home provides a wholesome, appealing balanced diet in pleasing surroundings. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 15 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) 16,18 Service users know who their complaints will be listened to and acted on. Service users are protected from abuse. EVIDENCE: The home has a procedure for dealing with complaints, which is in line with the National Minimum Standards. A copy of this procedure is attached to the Service User Guide and a copy is displayed at the home. Neither the Commission nor the home has received a complaint about the home since the last inspection. Service users told the Inspector they had ‘no complaints’. Service users said they would speak to staff if they had a complaint. Service users said they were confident that any complaint would be listened to and dealt with. All of the Service users spoken to said they had no complaints about the home and could not think of how the home could be improved. The Home has an adult abuse policy and a whistle blowing (public disclosure) policy. These policies include the procedure for reporting suspected abuse. Staff told the inspector that they report any suspicions to the Manager or to the Commission or social services. Staff attend adult abuse training as part of their induction then the training is offered on a rolling programme facilitated by the Home’s training coordinator. Staff attend refresher training every 2 years. The Inspector noted some shortfalls in adult abuse training; the Manager showed that a course for staff has been booked. The home is not responsible for Service users finances. Finances are dealt with by Service users themselves or by appointees. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 16 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) 19,20,21,22,23,24,25,26 Service Service Service Service users users users users live in a well-maintained, comfortable pleasant home. have sufficient bathroom and toilet facilities. know they will have the equipment they need. know their rooms and the rest of the home will be kept clean. EVIDENCE: The home and the garden are well maintained and decorated to a high standard. All communal parts of the home are accessible to Service users; there is step free access throughout the home and a stair lift to the first floor. Furnishings were seen to be of very good quality and domestic in nature. Al bedrooms and communal areas are attractive with lamps; pictures and ornaments making the home feel very homelike. The Inspector understands that the home complies with the requirements of the environmental health officer. The home has two large lounges on the ground floor and a large dining room. Lighting and heating was adequate on the day of the inspection. Service users told the Inspector that the communal space provided was sufficient to Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 17 meet their needs. Service users said that they like having a choice of lounges. There is also seating in part of the dining room. Some Service users prefer to sit here and relax. The home has grab rails and handrails fitted where necessary. Some specialist equipment has been obtained by the home to maximise Service user independence and health. For example, mobility aids, specialist cushions and mattresses. Hot surfaces, which have been assessed as a risk to Service users, have been guarded. All 17 bedrooms at the home are for single occupancy and all have en suite facilities. The Inspector met with 3 service users in their rooms. Service users told the Inspector that they were happy with their rooms. All said their rooms were kept ‘spotlessly clean’. The home was suitably fragranced even though staff are allowed to smoke in a designated smoking area off the dining room. Staff said that only 2 staff smoke and they follow strict guidelines. All rooms have a telephone point, a television point and a call alarm point. All Service users spoken to said they were happy with their rooms. The home employs a team of domestic staff. The home was very clean and orderly on the day of the inspection. The laundry was in tidy and clean. One Service user said she was not keen on the washing powder being used by the home although agreed it was sufficient. Service users said their clothes are well laundered and they always get them back promptly and in good condition. Hand washing facilities are sited appropriately throughout the home, although the Inspector noted that bar soap and cloth towels are used as well as disposable towels. Liquid soap should be provided and bar soap removed to prevent infection. There is a policy for the control of infection. Cleaning products are stored securely. All bedrooms have at least en suite toilet and wash hand basin facilities. There are also communal bathrooms and toilets sited close to communal areas. Baths are assisted to help maximise Service users independence. Service users said these facilities meet their needs. The home has a house bird in a cage in the lounge. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 18 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 Skilled competent staff support Service users. There are sufficient staff to meet Service users needs. Recruitment procedures are robust which protects Service users. EVIDENCE: The home employs 23 staff who work full and part time hours. The Home is staffed by two care staff on duty from 7.30am to 8.30pm. Some staff work 7.30am to 1pm or 2 pm then 1pm or 2pm to 5pm or to 8.30pm. At night there is a waking staff who works from 8.30pm to 8.30am and a sleep in staff who works from 8.30pm to 11pm then 6am to 7.30am. An extra carer is on duty for four hours five days a week to support Service users personal care needs. The Acting Manager plans the rota. There are domestic staff and a cook with a vacancy for a cook at present. There are two staff under 18 years who carry out domestic tasks. In addition to this there is always a Senior staff on duty seven days a week and the Acting Manager Monday to Friday. Senior staff said they share the on call responsibility. They said that extra staff could be called on depending on the needs of the Service users. Service users told the Inspector that there were staff on hand when they needed them and that when they have used the emergency call alarm staff were on hand promptly to offer assistance. Staff at White birch Lodge are mostly long standing and experienced. Service users said ‘Staff are kind’ ‘Staff are very good’ About 25 of staff at this home have a National Vocational Qualification (NVQ) in care at level2 or above. This is below the minimum standard of 50 of staff. The Acting Manager said that he has secured some funding for NVQ qualifications, which staff will commence soon. All staff have recently Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 19 undertaken a TOPSS- certified induction. Staff have access to a rolling programmes of training courses facilitated by the home’s training Manager. Courses for May, June, July and August 2005 included fire prevention, Dementia awareness, adult abuse, safe moving and handling and health and safety. The Acting Manager has completed a training needs analysis and has planned the required training to address any shortfalls. New staff follow a structured detailed induction. A new staff member told the Inspector about her induction which covered statutory training like fire awareness and health and safety. Staff spoken to had an understanding and knowledge of current Service users needs. One Service user described one night staff as ‘an angel’ The Inspector sampled staff files. Files are organised and held securely. These have been audited since the last inspection. Staff files contained the necessary documentation including two written references. All staff have the necessary Criminal Records Bureau (CRB) checks apart from two cleaners under 18 years of age. The Manager asked advice from the Commission about checks in respect of the two employees before the inspection. Both have the necessary references. CRB checks will be applied for in respect of these two employees to protect Service users. Staff said they have contracts of employment. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 20 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) 31,32,36,38 Service users benefit from a well run home. Service users benefit from well supervised staff. Service users know their health and safety will be protected. EVIDENCE: Paul Knight, the Acting Manager has now completed the qualification required by the National Minimum Standards and plans to apply for formal registration as Manager to the Commission. Mr. Knight is supported by the owners Mr and Mrs Squire and by the Manager of their agency who has an adjacent office. Two experienced competent senior staff support Mr. Knight also. There are clear lines of accountability with staff knowing who they would report to and when. The Acting Manager was knowledgeable about service users needs and spoke with empathy and understanding. The Inspector observed a daily hand over meeting between the two senior staff ad the Manager. This was a forum for open discussion. The Manager enabled the senior staff to make suggestions and exchange ideas, which were discussed and supported. Staff and Service users spoke positively about the management of this home. Staff said the Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 21 management is open and approachable. The Manager was observed giving clear direction and showed good leadership skills. Staff said there was always someone they could call on out of hours of they needed guidance or support. Staff have regularly one to one meetings with a line manager. These meetings are held six times a year. This gives the opportunity to discuss their role, any training needs and Service user issues. The Manager said that staff meetings are also held if there are any issues to discuss. Handovers are held daily between the morning and afternoon staff. Staff also use a communication book. Safe working practice topics are covered during staff induction. These included health and safety, fire awareness and safe moving and handling. Staff then attend refresher training on a rolling programme. Equipment at the home is well maintained with the necessary checks carried out. The home has the required health and safety policies. During the visit the senior staff carried out a check of the fire alarm and related systems. The Inspector noted that 2 fire doors near the dining room did not close properly. A requirement was made to address this. The Manager said that he would carry out an audit to ensure that all fire doors are working effectively. The Inspector sampled the water in the ground floor bathroom. The water temperatures are within a safe range. This home is a member of the Kent Care Homes Association and the National Care Homes Association. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 22 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 4 4 3 4 3 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x 3 x 2 Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 23 No 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 OP7 Regulation 15 Requirement Service user plans must contain the requiredd information including background history and any relevant guidelines. The Registered Person must ensure that there is a record of medication coming into the home. The Registered Person must ensure that all fire doors are working properly. Timescale for action 30/08/05 2. OP9 13(2) 30/08/05 3. OP38 23(4) 30/08/05 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. 3. Refer to Standard OP26 OP28 OP29 Good Practice Recommendations Bar soap should be removed and replaced with liquid soap. 50 of care staff should be qualified to level 2 NVQ in care by 2005. CRB checks should be applied for in respect of all staff including domestic staff. Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford Kent, TN23 1HU 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 Whitebirch Lodge H56-H05 S23624 Whitebirch Lodge V225023 060705 Stage 4.doc Version 1.30 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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