Inspection on 29/04/05 for Whitebourne

This inspection was carried out on 29th April 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Whitebourne 22/07/06

Whitebourne 07/11/05

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 Burleigh Road Frimley Surrey GU16 2EP Lead Inspector Helen Dickens(with Vera Bulbeck) Unannounced 29 April 2005 9.30 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. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Whitebourne Address Burleigh Road Frimley Surrey GU16 2EP 01276 854555 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) Care UK Community Partnerships Limited Mrs Rosalyn Gaye Hampson Care Home 63 Category(ies) of DE Dementia 55 years and over (1) registration, with number DE(E) Dementia - over 65 (57) of places OP Old Age (5) SI(E) Sensory Impairment - over 65 (1) Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide a placement for 1 named service user with DE Dementia over the age of 55 years. Date of last inspection 22 July 2004 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. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 9 hours and was.the first inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Lead Inspector for the service, with Vera Bulbeck as the second Regulation Inspector. Mrs. Rosalyn Hampson was present representing the service. A tour of the premises was carried out and a variety of records inspected. A number of residents, visitors and staff were spoken to during the course of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 6 There is still some room for improvement with regard to the administration of medication and a visit from the pharmacy inspector was recommended. There were also instances where resident’s care plans and assessments, and staff training records, were not quite up to date. One inspector observed that lunchtime was rather rushed. It was also noted that most residents still do not have their room number included in their contract with the home, and not all staff have a photograph on their file; these were outstanding requirements from the last inspection. 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 H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 The new contracts and thorough initial assessments mean residents and their relatives/supporters will have a clear understanding of their rights within the home and can be confident their care needs are properly acknowledged on admission. EVIDENCE: The contracts recently issued by Care UK Ltd have made a number of improvements; in particular they state the room number allocated to the resident on admission. However, only new residents are given these contracts, and therefore existing residents still do not have a particular room allocated to them in their contract. This is an outstanding requirement from the last inspection. It was also noted that the new contracts mention ‘nurse and care for you’ and the ‘senior nurse’, which may give the mistaken impression that this home offers nursing care. The initial assessments sampled were of a good standard and showed consideration of the wide-ranging needs of new residents. The inspectors Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 9 noted that staff were knowledgeable on the backgrounds of residents, for example one resident who ate a lot of salad was known to have been a model. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 9 Progress has been made on making sure that resident’s health, personal and social care needs are met. A review of medication handling was undertaken by a CSCI pharmacist inspector who found the home had procedures in place for administering and recording medication and could demonstrate safe practices. EVIDENCE: The service user plans sampled had improved since the last inspection and there was evidence that resident’s health, personal and social care needs had been identified and assessed. A resident whose needs had changed recently had this well documented on the file and specialist medical advice had been sought before family and home agreed the resident needed to move to a higher level of care. However, some service user documentation was overdue for review and initial assessments were not individually dated which made it difficult to follow without referring to other parts of the file. Other issues important to resident’s wellbeing (e.g. missing false teeth) were not recorded. One visitor said that nails needed cutting on the hands and feet of the person they visited. Medication stocks and records were sampled and showed the majority of Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 11 residents were receiving their medication as intended by their doctors. However, there were no clear instructions for administering a night sedative to one resident where the dose prescribed was 1 to 3 tablets. Also there was no care plan, nor training, for staff for the treatment of a resident prescribed an injection for the treatment of anaphylaxis. Other medication was administered by authorised staff who had received training and who worked to documented procedures. At this time no residents were administering their own medications. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The home continues to increase the social and recreational opportunities available to residents; this provides a more stimulating environment and helps improve the quality of life for residents. Dietary requirements of residents are well catered for. EVIDENCE: There is a monthly programme of activities including art and craft, reminiscence and bingo. On the day of the inspection there was a change from the activities listed and some residents were enjoying a game of carpet skittles. An additional activities co-ordinator is currently being recruited. The activities co-ordinator was knowledgeable on the mixed capabilities and interests of residents. Residents had mixed comments on activities. When asked what she did all day one resident replied “Not a lot. When they do have activities, they are very good.” Another replied, “Not much, chat and watch telly.” There were few visual memory aids available to residents and some of those available might have been rather confusing, for example a resident’s clock which had stopped; and a TV on (with no-one watching it), was distracting the residents who were trying to concentrate on the skittles. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 13 The food served on the day of the inspection did cater for the different needs of residents for example mashed potato for those who couldn’t eat chips, and steamed fish for those who couldn’t eat battered fish. There were two other alternatives. Residents made favourable comments about the food. One said, “I just look at this and I know it’s got to be good.” The lunches did seem to be rather rushed, particularly on the ground floor, and residents sitting together were not necessarily served at the same time, leaving some eating and others sitting without food. There was a fairly loud radio playing in the upstairs dining room during the meal. The tour of the kitchen showed consistent record keeping, well stocked fridges, freezers and store, and evidence that fresh vegetables and homemade fayre were usually on the menu in this home. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, and 18 Complaints are taken seriously, and training and arrangements for the protection of vulnerable adults are in place. This goes some way to ensuring that residents are safeguarded from abuse. EVIDENCE: There were six complaints on record since the last inspection and these were well documented and investigated by the manager; items of clothing going missing was raised as an issue several times during the inspection. A residents survey carried out by the home was also being used as a tool to explore further areas for improvement. The training programme and records showed that staff were attending vulnerable adults training, and records on accidents/incidents were well kept with more detailed documentation on those clients who were prone to falls. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21 and 26 The standard of hygiene, décor and safety in the home is good, providing service users with an attractive and homely place to live. EVIDENCE: Whitebourne is accessible, safe and well maintained. The home benefits from a dedicated worker who deals with both routine and unexpected maintenance duties. Annual maintenance of an assisted bath was due and the maintenance worker immediately confirmed with the company that their visit was planned for the coming week. The manager said new locks have been fitted to the garden gates as some residents had worked out how to negotiate the existing locks. There were sufficient toilets and washing facilities as all residents had these ensuite. Water temperatures were checked in the first floor assisted toilets/bathrooms and in four residents bedrooms and found to be safe. The standard of decoration was good. One resident who was happy with her Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 16 room said that her bathroom was “gorgeous” and another who was sitting in a small lounge said it was “a beautiful room.” Notes from the relatives/residents meeting and feedback from the residents survey revealed many positive comments on the cleanliness of the home and standard of furnishings. There were some concerns about the odour in one resident’s room. and during the inspection two visitors commented about the smell in the corridors at times. One resident’s bedroom needed some attention to the walls, and another resident’s room had no call bell. Hoists and wheelchairs were still been stored in the hairdressing salon as no other suitable storage area had been identified. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Staffing levels, training arrangements and morale had improved and this was having a positive effect on the care and quality of life of residents. EVIDENCE: Staffing levels had improved and there were 12 care staff on throughout the day (including 2 team leaders) plus the manager and her deputy. During the night shift there were five staff including a team leader. Total hours in the laundry now amounted to 49 hours per week, and an extra activities worker was currently being recruited. Recruitment policies were generally good and the manager had applied to be a registered signatory for checking CRB documentation, which means all such records, could be kept in the home. However, staff records on recruitment showed some omissions and this needs to be addressed. There were some concerns about the potential risk to residents as staff records showed one reference had not been taken up, and another had ‘gaps’ in the CV, which needed exploring. Staff training is improving and records were available to show the ongoing programme of courses. Some individual training records examined needed updating. Though the training available to permanent staff was good, the manager needs to consider the training and qualifications of ‘bank’ staff who need to be included in the target of 50 trained members of care staff (NVQ level 2 or above) by the end of 2005. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 18 Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,36,37,38 The leadership and management of the home is strong and the manager has brought about improvements in a number of important areas. EVIDENCE: The management approach of the home has created an open and positive atmosphere; residents, visitors and staff spoke freely with inspectors on a variety of subjects. Residents/relatives meeting notes were available, as were the results of a resident’s survey. Individual care plans showed evidence of gathering information about the wishes and preferences of residents. A system for staff supervision was now in place, the inspectors saw the supervision template, and relevant staff have received training in giving supervision. Record keeping was good though there were some instances of resident’s records not being completely up to date. The fire risk assessment needs to include the whole home and the up-dated Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 20 fire plan was not on file. There was evidence that the the health, safety and welfare of residents was being promoted, and a training programme in place for staff, which included the relevant topics. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 3 3 x x x x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 2 x x 3 2 2 Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 22 yes 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. 2. Standard 2 7 Regulation 5 15 Requirement Service users contracts must include room numbers (Previous requirement by 10.09.04) Service users plans to be reviewed and updated to reflect changing needs and current objectives for health and personal care and actioned The registered person must have a clear care plan, giving detailed instructions to staff as to what dose to give when a variable dose of night sedation is prescribed for service users, following consultation with the relevant GP. This will ensure that medication is administered in a clear and consistent way for the benefit of service users. For staff training in anaphylaxis and administration of prescribed medication by injection in medical emergencies with a clear protocol agreed by GP The bedroom of one service user needed attention and decoration The home to allocate a storage area for hoists when not in use.(Previous requirement by 01.10.04) The bedroom of one service user Timescale for action 29 June 2005 29 May 2005 3. 9 13(2) 1 June 2005 4. 9 13(2), 18(1) (c)(i) 23 23 1 June 2005 5. 6. 19 22 29 June 2005 29 July 2005 Immediate Page 23 7. 22 23(2)(n) Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 8. 26 16(2)(k) 9. 10. 29 29 19 19 11. 12. 30 32 17(2) 12 13. 14. 15. 33 36 38 26 18 37 had no call bell - this needs to be -from date rectified . of Inspection The bedroom of one service user 29 May had offensive odours in the 2005 bedroom and bathroom areas and this needs to be addressed. All staff must have a recent 29 June photograph on file. 2005 Recruitment procedures need to 29 May be reviewed to make sure all 2005 prospective staff have two written references taken up, and any gaps in employment records are explored. Staff training records in the 29 June home need to be brought and 2005 kept up to date. Staff notices to be removed from 6 May areas used by service users, in 2005 particular from the first floor assisted toilet. Regulation 26 visits should be 29 May available in the home, signed 2005 and dated. Staff supervision needs to be 29 June increased 2005 Accidents/incidents which 6 May adversely affect the well-being 2005 or safety of service users, should be reported under Regulation 37 to CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 12 15 Good Practice Recommendations The home may wish to consider the use of more memory aids for service users and to be aware of distractions (such as TV and radio) when other activities are taking place. The home should give consideration to making meal times less rushed, and, where possible, to avoid giving medication when service users are eating. H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 24 Whitebourne 3. 4. 5. 19 19 The fire risk assessment to include the whole home. Storage of potatoes should be off the floor. Whitebourne H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 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 H58-H09 s39537 Whitebourne v219209 290405 Stage 4.doc Version 1.30 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!