Inspection on 22/07/06 for Whitebourne

This inspection was carried out on 22nd July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Whitebourne 07/11/05

Whitebourne 29/04/05

Whitebourne 22/07/04

Whitebourne 14/04/04

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 Whitebourne Whitebourne Burleigh Road Frimley Surrey GU16 2EP Lead Inspector Damian Griffiths Key Unannounced Inspection 22nd June 2006 09:00 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 Whitebourne DS0000039537.V299502.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. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitebourne Address Whitebourne Burleigh Road Frimley Surrey GU16 2EP 01276 20723 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) manager.burroughs@careuk.com Care UK Community Partnerships Limited Rosaline Ann Stevenson Care Home 63 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (57), Old age, not falling within any other of places category (5), Sensory Impairment over 65 years of age (1) Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide a placement for 1 named service user with (DE) over the age of 55 years. 7th November 2005 Date of last inspection Brief Description of the Service: Whitebourne is a purpose built home designed for older people with dementia care needs. It is located in a residential area in Frimley and within walking distance of shops and local facilities. The home is owned and managed by Care UK Limited and is registered to accommodate 63 older people. The reception and managers office are off the main entrance area. Residents accommodation is arranged on the ground and first floors, with the second floor being for staff only. Residents live in one of five suites, two of which are on the ground floor, and the other three on the first floor. The suites are interlinked and have a number of lounges and communal areas. Each floor has a dining room and a small kitchen. There is a passenger lift. The homes other facilities include a kitchen and laundry room. The home has a pleasant grassed area enclosed by wooden fencing, and there is adequate parking to the front and rear. Costs per Week: £750.00 to £850.00. Please note this price may vary due to the level of care needs assessed. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the Commission for Social Care Inspection (CSCI) year April 2006 to 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Lead Regulation Inspector Damian Griffiths was assisted throughout the inspection by the Registered Manager Mrs Rosaline Stevenson representing the establishment. The IBL process involves a pre-inspection assessment of service information from a variety of sources initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. A new ‘Inspection record’ is compiled from details of the previous inspection and details supplied by the home included a pre-inspection questionnaire and notifications of significant events known as regulation 37. Comments and complaints received and previous inspection reports are all considered for inclusion to the Inspection record prior to the inspection visit. For more details of ‘IBL’ please visit the Commission for Social Care Website details can be found on the last page this Inspection report. The inspector was with staff and residents at Whitebourne for a period of 7½ hrs. This time was spent sampling resident’s care need assessments, care plans, contracts and talking to residents, staff. Staff files were inspected for evidence of good practice in the following areas: recruitment, allocation of staff skills, daily rotas and training. Residents and relatives and a GP for Whitebourne were able to complete CSCI questionnaires that have been included in this report. A tour of the premises and grounds was completed and the inspector was able to confirm that comments made in the questionnaire by meeting staff and residents of the home. The inspector would like to extend thanks to the residents staff and management at Whitebourne for their assistance and hospitality. What the service does well: A good rapport was observed between residents and staff during the inspection. Assessments of care for new and existing residents was good and the care plans produced were clearly recorded. The home had introduced a computerised system where care plans can be written, reviewed, and daily information updated for the benefit of the staff and residents. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 6 One to-one time was available to residents and there was a good selection of activities available that encouraged residents to maintain links with the local community, meeting people and visiting events outside of the home, such as trips to the seaside, the local pub and supermarket. For residents that did not wish to leave the home events such as cheese and wine party and a visiting farm had been arranged. Friends and relatives commented on friendly welcome received by the management and staff of Whitebourne. The home environment itself was welcoming, clean, airy, and comfortable and allowed the residents good access throughout the home and grounds. CSCI Comment cards completed by Residents, friends and relatives were all very positive. What has improved since the last inspection? 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. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. 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. Residents had received good assessments of need prior to admission and care plans reflected the tasks required. Intermediate care was not available at this home. EVIDENCE: Six files were sampled, including those of recent residents to Whitebourne. Assessments were comprehensive and details covering areas such as: mobility, physical and mental health, tissue viability, and personal information. The manager was aware of how difficult it can be for a resident entering the home for the first time and to be subjected to a potential barrage of questions required when formulating an accurate care plan. The manager explained that she had halted an assessment process at the request of a resident in the past and would always seek to elicit details from other sources whenever appropriate. The manager will visit potential resident at home to assess their needs or they may visit the home for afternoon tea or experience as ‘short stay’ at the home. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 9 Comments received in the CSCI survey confirmed that: residents felt; well cared for and were, also treated well. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 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 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. Residents’ benefit from detailed and well-produced records containing up-todate information about social and health care needs. Staff respected residents privacy and consulted residents about their daily needs. EVIDENCE: Six care plans were sampled for details of how residents care had been compiled: the tasks required to ensure health and safety was being provided, and to establish whether health needs were being met on a regular basis. There had been a substantial amount of falls recorded by the home due to the nature of the residents needs however each fall had been recorded, assessed and actioned in a speedy and positive manner with the aim of reducing risk and promoting a reasonable level of independence for the resident. A new system of computerised care planning had recently been introduced and staff were beginning to use this system. It was accessible to each team leader and located in the staff room. Senior staff were observed typing up new reports and the home aims to train all staff to be able to input and update care plans and daily charts. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 11 Residents’ health care needs and required hospital, clinical appointments were in evidence in their care plans and risk assessments had been compiled and indicated the potential for injury, for example, falls or tissue breakdown. This contributed to the overall care plan of the resident and alerted staff to these areas of care. Residents’ files showed that they had been regularly monitored for weight loss/gain, fluid intake, mental health status, manual handling, aggressive behaviour and nutrition. Staff administered prescribed medication to the residents in their care had recorded some instances of maladministration over the course of the year. Administration of Medication was checked and records sampled corresponded with the correct GP prescribed medication, dose and amount of tablets distributed and drug returns record was all in order. All drugs retuned to the pharmacist were recorded correctly in the drugs return book and were signed in by the Pharmacist. Drugs waiting to be returned were inspected and ‘MAR’ charts examined all corresponded to the record. The pharmacists that supply all the homes medication agreed a recommendation, made by the inspector, to record each drug return by stamping the page of the drug record with the pharmacies own official ‘stamp’. Comments included in the CSCI survey also confirmed that the GP agreed that the residents benefited from staff understanding the needs of the residents, specialist services were incorporated into care plans, and private GP consultations occurred. The residents were observed being treated with dignity and respect by staff. First names were used and doors knocked prior to entry into a resident’s room. Staff were observed asking resident’s about their meals preferences and talking to them about daily activities and general interest. Residents consulted, felt that they were given ‘ample time alone’ and their privacy was respected. Comments recorded in the CSCI survey confirmed that residents: liked the food, privacy was respected and staff treated them well. New residents to the home and their relatives were satisfied with the care received and could gain support from ‘The Friends Of Whitebourne’. . Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ preferences and choices were respected, activities were appropriate and to residents’ needs and presented a positive image. The home ensured that relatives’ and friends were always welcomed and resident’s choices were respected. Resident’s meals were good offering both choice, variety and catering for special dietary needs. EVIDENCE: Activities were age appropriate and met the cultural needs of the residents who had the opportunity to visits the local church, visit the pub or do some personal shopping at the supermarket. Residents were observed receiving one-to-one attention from staff who would also support residents with various activities going on at the home including events such as a St Patrick’s day party, a cheese and wine party or farm animals coming to visit for the day. Residents were supported and encouraged to join a party of others for a days out, feed the ducks in the park visit a pub or a museum. Outings to the Royal Horticultural Society at Wisley and other day trips were also available. There was evidence of regular outings occurring approximately twice a week Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 13 ‘The Friends Of Whitbourne’ consisting of friends, relatives and interested parties were also available to organises or participate within the homes busy social calendar and produced a monthly newsletter that helped to boost everybody’s interest in what was going on and encouraged new ideas. Residents could also receive regular attention from the visiting hairdresser, chiropodist and received daily newspapers and magazines of their choosing. The majority of residents were English but some residents were of European origin but had been well integrated into the English culture. The home had a multicultural workforce who on most occasions were able to speak in the language of the country of origin to residents who at times would not be able to communicate in English. The menus and food observed on the day of the inspection was very good. Menus provided a choice of two different meals a day, fresh fish, fruit and vegetables and special diets such as reduced sugar or salt were available. All residents commented on the good food available. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 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 the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff understanding of the appropriate procedures designed to safeguard residents, complaints were acted on and residents felt safe and well cared for. EVIDENCE: Relatives commented on their satisfaction with the way the home was run and stated that they had never had to make a complaint however there were some residents and relatives that had, and their complaints had been properly recorded. The complaints system was in place and five complaints had been made over the last twelve months, three of which the home had found to be partially substantiated. A full account could be found on record with the actions taken and outcomes. Relatives confirmed that they were consulted about important matters and consulted about their care. Residents felt ‘safe’ at the home. Surrey Procedures for Safeguarding Vulnerable Adults was in place and available to staff. Staff consulted said they understood the indicators of abuse and the need to report any suspicions they may have to the manager or use the procedures in place for whistle blowing. There were no cases being investigated and there had been no reports made in the last 12 months. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 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 the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefited from a bright and cheerful place that was clean, light and airy and provided a nice homely environment. EVIDENCE: The Friends of Whitebourne’ contributed a tasteful flower arrangement within the entrance lounge creating a pleasant theme that set the overall tone of the premises well A tour of the premises was conducted with the help of the manager and various residents who contributed to this report. The home is now three years old and was showing some signs of wear and tear to wallpaper and paintwork. The grounds were in good order and safe for the residents to use. Residents had full access to the home and appropriate safety measures ensured that the kitchen and laundry areas were secured. These areas were also clean and hygienic as were communal bathrooms and the resident’s rooms. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 16 Each resident had their own name on the door to their room containing personalised décor, furniture and ornamentation. There were no areas of concern observed and the home possessed all necessary equipment that was in working order such as bath chairs and hoists. Overall the home was clean, tidy, without losing any sense of being a homely environment that was comfortable to live in. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Training received by staff adequately met the needs of the residents but it was not clear whether 50 of staff had acquired minimum levels of training required by regulation. The recruitment procedure fell short of being robust however staff were able to meet the skill mix required to ensure a good level of care was delivered. EVIDENCE: Staff rotas’ for the day were compared with the resident need and staff ability to establish whether a reasonable level training had been attained by the staff to ensure good care was being given to the residents. The staff on each shift had the required mix of skill and qualification required. Training received included: initial induction training, fire safety, health & safety and coshh, safe handling, safe handling of medication, food hygiene, safeguarding vulnerable adults, working with friends and relatives and dementia awareness. It was not clear whether 50 of staff were NVQ level 2 trained as required by National Minimum Standards however the home had supplied a good list of training achieved and new courses had been booked at the local college. Four staff members were consulted. Comments received: ‘Training very good’, ‘I have received more training here than the rest of the jobs (I’ve done) put together’. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 18 Five staff files were sampled for evidenced of robust recruitment procedures. Only one out of the five files showed a full employment history and CV. The inspector was informed that it was Care UK’s policy to require only 7 years employment history. One other file contained a reference from a person admitting to knowing the staff member for only a few months. Please see the recommendations and requirements section of this report. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Staff and residents felt well supported by the management style of the home. Residents benefited from regular residents meetings and support from relatives and advocates. Residents Money was safely handled and recorded and Health and safety at the home was well managed and implemented. EVIDENCE: Staff consulted felt supported and could rely on the manager and management system to respond to any of their concerns or worries and comments received included: ‘there is no pressure to work longer hours and ‘I get enough time to complete my tasks’. Residents and relatives meetings were three to six times a year and advocates for residents with dementia needs was available as well as, Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 20 ‘The Friends Of Whitebourne: an established action group had a constitution and had been very proactive raising £6,000 recently. Two samples of residents financial accounts were inspected, records were checked against receipts and cash was counted all were in order. The homes record keeping and accounting was in good order and procedures matched the description listed in homes statement of purpose. Health and safety was well documented. Insurances were in place: fire drills and extinguishers checked, equipment checked, COSHH, water temperatures physically checked and correct, training in place. There were no concerns or complaints reported regarding Health and Safety at the home. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP29 Good Practice Recommendations It was recommended that staff with references from people that have known them for a short period of time should obtain a third reference that can reasonably be accepted as genuine and framed around that persons suitability for the relevant work as specified by the home and that all employment records be full and without any unexplained gaps. Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Whitebourne DS0000039537.V299502.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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