Inspection on 13/12/06 for Whitefriars

This inspection was carried out on 13th December 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

Whitefriars 27/10/05

Whitefriars 14/03/05

Whitefriars 25/02/05

Whitefriars 06/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Whitefriars St. George`s Avenue, Ryhall Road Stamford Lincs PE9 1UN Lead Inspector Mr David Bacon Key Unannounced Inspection 13th December 2006 08:00 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 Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitefriars Address St. George`s Avenue, Ryhall Road Stamford Lincs PE9 1UN 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) 01780 765434 manager.whitefriars@osjctlincs.co.uk www.oxfordshire.gov.uk The Orders Of St John Care Trust Mrs A G Grummitt Care Home 60 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (40) of places Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. It is a condition for all DE(E) service users to be accommodated in `Jasmine` unit only. The home is registered to provide personal care to service users whose primary needs fall within the following categories:Old age, not falling within any other category (OP) - 40 and Dementia - over 65 years of age (DE(E) - 20. The maximum number of service users to be accommodated is 60. 3. Date of last inspection 27th October 2005 Brief Description of the Service: Whitefriars is a 60 place, purpose built residential home for Older Persons and Older Persons having dementia. The home is situated in the market town of Stamford, adjacent to a residential area and within close proximity of a post office, a small group of retail outlets and supermarket. Car parking for at least twenty vehicles is situated to the side of the home. All accommodation is on the ground floor level and the majority of bedrooms are single occupancy. The home has 4 units which all contain lounge/dining areas and a small kitchen where service users can make drinks if they wish. All main meals are prepared in the main kitchen area. The home is one of a group of homes run by the Order’s of St John Trust and its stated aim is to provide a homely, relaxed and caring environment that takes into account the individual needs of the residents. Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place over 4.5 hours; it was unannounced and was carried out by one inspector. A tour of the premises was conducted, service users care records and staff records were inspected along with administrative systems. The care received by three service users was looked at in detail. This process is called “case tracking” and individual service users care records and general home records were looked at as part of this. Two staff members and the responsible person were spoken with and also a visiting district nurse. Other service users were spoken with about general standards of care and life within the home. Feedback was also received prior to the visit from surveys completed by service users. The homes fees range from £336 to £510 per week. What the service does well: What has improved since the last inspection? No requirements were placed upon the home during the previous inspection visit and since then a customer satisfaction survey has been undertaken by the home, which indicated good overall levels of satisfaction regarding the care provided and that service users views were being acted upon. Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Whitefriars DS0000002476.V322354.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 Whitefriars DS0000002476.V322354.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a contract of stay although some individuals care needs are not clearly recorded. Service users are satisfied with the admission process. EVIDENCE: The care records viewed demonstrated that an assessment of each service users care needs had taken place although some of the information within these was brief overall, which could potentially restrict staff members awareness of service users care needs. However, The care staff spoken with were clearly aware of service users care needs and how these were met. The completed risk assessment information identified the risks to each service user and instructed staff how these were to be minimised. Records demonstrate that service users are given a contract of stay. Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 9 The service users spoken with were satisfied with the homes admission arrangements and how staff involved them in the care provided. Comments included: “As I said, the staff are and have been tremendous, and from the beginning”. “They couldn’t have done more really, super staff, kindness itself”. “They gave you all the information you needed and you can ask anything and they are so helpful”. Whitefriars DS0000002476.V322354.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users spoken with feel they are treated with respect and they are satisfied with the care and health care provided although some care records only provide staff with basic information about service users care needs. Procedures for the administration of medication are appropriate. EVIDENCE: Care records overall identified service users care needs although a care plan had not been fully completed for one service user recently admitted to the home. The care staff spoken with were aware of the service users care needs, which was further evidenced in the service users daily care records and senior staff addressed this matter during the visit. A risk assessment is undertaken for each service user although these do not identify all risks and the action to be taken to minimise these. For example, one service user had recently suffered a stroke and although care staff were fully aware of this it was not clearly documented in the service users care Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 11 records. Records did not clearly document that service users had been consulted with regarding their plan. Other care records seen were generally updated daily or with any changing care needs and reviewed each month. The care plans viewed identified that service users health care needs are monitored, that the home accesses professional advice and that appropriate action is taken as necessary. For example, one service user was receiving district nurse input and their care records detailed the care being provided by the nurses and any given instruction or advice. The district nurse spoken with said that they were satisfied with standards of care in the home and that care staff followed any given instruction or advice. The service users spoken with were satisfied with standards of care within the home and that staff treated them with respect, which was further evidenced within the completed quality satisfaction surveys seen. Staff during the visit were observed interacting with service users in a respectful manner. The homes medication system was well maintained and documented medicines as receipted into the building, where administered and as disposed. Medicines are securely stored and staff whom administer medication receive awareness training regarding this and policies and procedures are available for staff. Whitefriars DS0000002476.V322354.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The services users enjoy the food provided by the home, they can choose how they spend their time, they enjoy the activities available and their visitors are made welcome. EVIDENCE: Policies are in place to assure service users that they are able to spend their time as they like, that their individual rights are promoted. Service users confirmed this and that their visitors are made welcome to the home. Written information provides guidance to staff regarding promoting service users rights, independence and choices and staff initially receive information regarding this during induction to the home. A menu is produced, which is displayed in the home and regularly changed, as per the views of service users. The home cook was aware of individual service users dietary needs and also said that the majority of meals are home produced, which was evidenced during the visit. A record of all meals provided is maintained along with equipment temperature records and a cleaning schedule. The service users spoken with expressed high levels of satisfaction regarding the homes meal provisions. Comments included: “I’m satisfied with Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 13 the food, sometimes its better than others but really it would be very hard to beat”. “They make meals for a lot of people and it is very good”. “You have a choice of foods, at any mealtime you could have something different”. A variety of activities are made available to service users by designated staff and service users views regarding recreation is sought on a regular basis and acted upon. Whitefriars DS0000002476.V322354.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to ensure that service users are protected from abuse and service users feel that they can voice any concerns if they wish. Staff are aware of the homes whistle blowing and safeguarding adults policies and procedures. EVIDENCE: There have been no complaints or safeguarding adult referrals made since the last inspection site visit. The homes complaints procedure is displayed in the home and included within the service users guide. The service users spoken with said they felt able to complain and comments included: “I don’t have any complaints but you are given information about this”. “You can talk with any of the staff or the manager if you need to say anything but I have no complaints”. “They are all kind, you can say anything you like really, well I do”. “If needed you would say your bit and I’m sure they would sort it”. The staff members spoken with were aware of abuse and whistle blowing policies and procedures confirmed that they had received information regarding this subject matter. Awareness training regarding safeguarding service users is ongoing for staff. Risk assessments are undertaken for each service user and information regarding advocacy services is provided. Whitefriars DS0000002476.V322354.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is very well maintained, clean and comfortable and it meets the individual needs of service users whose health and safety is protected. Some fire safety records are not always accurately updated. EVIDENCE: The home is well maintained, well lit and decorated, having comfortable communal areas, and service users are supported to personalise their own rooms. Hot water temperatures are monitored monthly and risk assessments regarding this and for the prevention of legionella are in place along with other infection control policies and procedures. Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 16 Designated cleaning staff are deployed each day and they keep the home clean and odour free. Health and safety policies and procedures are in place for staff, who receive awareness training regarding this. A risk assessment has been undertaken of the premises and of individual service users. Service users comments included: ”It’s always nice and clean, it was one of the first things I noticed.” “They keep your room clean, It’s a lovely place really” “The cleaning staff are very good, you can talk with them.” There is an up to date fire risk assessment available within the home although the fire safety records seen did not fully demonstrate that fire safety systems were being tested as per fire safety regulations. For example, records of emergency lighting and fire system tests. The senior staff member stated that this was due to a new fire safety system being installed, which was further confirmed by the fire system engineers present during the visit. The senior staff member also demonstrated that this matter was addressed during the visit. Whitefriars DS0000002476.V322354.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff and significant recruitment and induction procedures are in place to safeguard and to meet the needs of the service users. Staff overall have the skills and experience necessary to carry out their roles. EVIDENCE: The service users spoken with expressed high levels of satisfaction regarding the homes staff and confirmed that their care needs were met. Service users comments included: “They are a good lot, you like some more than others but they are not a bad lot, you can have a laugh and the care is provided”. “I have been very well treated by the staff”. “They seem well trained and they know how to look after you”. “You can’t really fault them, you don’t wait too long and they are respectful, no complaints”. The staff records viewed clearly documented that comprehensive recruitment policies and procedures are in place. These include equal opportunities monitoring, application and interviewing systems and records. The staff members spoken with were satisfied with the homes induction and training programmes, of which highly developed systems are in place, which was further evidenced in the staff records viewed. Comments included: “The Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 18 induction was comprehensive and there was a good amount of support”. “You do receive good training and support, you can request to go on courses that are relevant”. Newly recruited staff are also supervised and a comprehensive training plan is in place for all staff relevant for the needs of service users. Whitefriars DS0000002476.V322354.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed and systems are in place to ensure that care is provided in a safe and appropriate manner. Comprehensive quality assurance systems are in place and staff are provided with information and support to provide a quality service. Systems are in place to protect service users finances. EVIDENCE: The registered manager has considerable experience in managing and working within residential care settings and has attained a nationally recognised management qualification; and maintains awareness of service user care needs through a continuous training programme. Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 20 The staff members spoken with commented about the individual support and supervision they received and said that they were satisfied with the manager’s approach to the role, which was further confirmed by the service users and visiting health professional spoken with. Comments included: “It’s a well run home, they are friendly and helpful, I can’t fault the care”. “You can ask anything and know that it will be followed up”. “They are keen to do the right thing for the residents and if they make mistakes then they want to put it right”. “I can’t complain because it would be difficult to beat this place”. The views expressed by those spoken with during the site visit were further confirmed in the completed quality satisfaction surveys seen, which are regularly undertaken. Also, the organisation who will involve external managers as part of quality monitoring. A risk assessment of the premises had been undertaken, which is reviewed as necessary and the staff members spoken with were satisfied with the homes management of health and safety of which designated training is provided. Individual risk assessments of service users are also undertaken. Systems are in place to safeguard service users rights, including finances where the home has any involvement in these and information regarding this is provided to service users through the statement of purpose, service users guide and individual contract. Also, practice handbooks are provided to staff and regularly updated. Whitefriars DS0000002476.V322354.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 X 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Whitefriars DS0000002476.V322354.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13 (4) c 14 (2) 15 (1) (2) 23 (4) Requirement Timescale for action 28/02/07 2 OP19 A comprehensive care plan must be completed for each service user, which must clearly identify each service users needs and demonstrate how these are met. Fire safety records must 28/02/07 document that fire safety systems be tested as per the Fire Safety Officers instructions. 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 OP3 Good Practice Recommendations Care assessment information should clearly document service users care needs. 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