Inspection on 27/10/05 for Whitefriars

This inspection was carried out on 27th October 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

Whitefriars 13/12/06

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 Unannounced Inspection 27th October 2005 08:15 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.V254631.R01.S.doc Version 5.0 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.V254631.R01.S.doc Version 5.0 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 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.V254631.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. It is a condition for all DE(E) service users to be accommodated in `Jasmine` unit only. 14th March 2005 Date of last inspection 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 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.V254631.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 4 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. The inspector spoke with the manager of the home and five staff members. Six service users, three service users representatives were spoken with along with a visiting health professional. What the service does well: What has improved since the last inspection? What they could do better: Minor adjustments are required with the assessing of risks within the environment and staff training. For example, a risk assessment must be completed for the premises and staff must attend Dementia awareness training. It is acknowledged that some action has been taken regarding these. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 6 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. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 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.V254631.R01.S.doc Version 5.0 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, 4, 5 Satisfactory procedures are in place for the guidance of care staff in undertaking pre-admission assessments and the introduction of residents to the home. EVIDENCE: The care records viewed evidenced that each service users care needs had been assessed prior to admission. The completed risk assessments identified the needs of each service user and any risks. Written confirmation is now sent to service users where the home is able to meet their individual care needs. The service users and representatives spoken with were satisfied with the homes admission arrangements and confirmed that they had visited the home without having a prior appointment and that they were made welcome. Comments included: “Oh I’m very satisfied with the admission to the home, the carers were friendly, yes it was handled well”. “I didn’t intend to stay but I Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 9 can say they made me very welcome”. “I don’t really remember much of it but when we visited and the staff were kind and helpful”. The home does not provide intermediate care services. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 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, 10 Care records provide staff with sufficient information overall to meet service users care needs and service users feel that they are treated with respect. Procedures for the administration of medication are well maintained. EVIDENCE: The service users and representatives spoken with confirmed that staff respected their privacy and dignity. Comments included: “The staff are tremendous, really, you don’t get on with them all the same but they are all kind and they help you”. “Yes, they look after your dignity and treat you properly”. During the visit she staff were observed carrying out care tasks and they were respectful to the service users. A care plan is completed for each service user and information within these is clear although minor adjustments are currently being made to more fully document how each individual’s care needs are met. The completed risk assessments identified any potential risks and the action required to be taken by staff to minimise these. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 11 Care records are generally updated daily and are reviewed as and updated as service users care needs change although they did not fully document where service users or their representatives had been consulted with regarding their care plan. The care plans viewed evidenced where residents were seen by health care professionals in relation to their health care needs. The community nurse spoken with was satisfied overall with the standards of care provided and felt that care staff followed any given instruction or advice. Comments included: “Generally, the homes does very well, they listen to any instructions and do the right thing”. “I would say that we are satisfied with how the home operates and the care provided”. The homes medication system was well maintained and clearly documented medicines as receipted into the building, where administered and as disposed of. Medicines are appropriately stored and staff who administer medication receive specific training regarding this. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 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): 13, 14 Service users are supported to express their views regarding life within the home, the care they receive and they can maintain and develop any community links as they prefer. The relatives and friends of service users are made welcome in the home. EVIDENCE: The service users and representative spoken with confirmed that they were no restrictions as to how residents spend their time and that staff respected their individual wishes and preferences. Comments included: “As far as I know you can do as you like, stay in or go into town, as you like”. “We do what we want, when we like”. The staff make us welcome, we visit here often and they are very good”. “They are all approachable and they treat you well”. “I’ll tell you, they all make you very welcome and it’s a nice atmosphere”. Service users confirmed that they are consulted with about their likes and dislikes and they have opportunities to express their views at residents meetings and on a daily basis. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 13 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): 16, 18 The service users spoken with feel able to express their views regarding the care they receive and complaint guidelines are in place regarding this. Staff are aware of the homes whistle blowing policies and procedures. EVIDENCE: Complaint policies and procedures are in place and information regarding these is provided to service users. The service users and representative spoken with said that they felt able to voice any opinions regarding the home and that any comments would be acted upon. Comments included: “I have spoken with them before and yes they did listen”. “I know I find them approachable and I would complain if I needed to”. The staff members spoken with were aware of the correct action to be taken in the event of an issue of abuse being suspected. Staff attend abuse awareness training and policies and procedures regarding complaints, whistle blowing and abuse are in place. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 14 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, 20, 22, 25, 26 The home is very well maintained overall and provides a comfortable and homely environment for residents. EVIDENCE: The service users and representatives spoken with were satisfied with the physical environment. Comments included: “Yes, it’s clean enough and always so”. “Its nice isn’t it, quite homely”. “They do a good job with it all really, its spick and span”. Service users can gain access to all areas of the home although the external doors are alarmed or have keypads fitted to minimise risks to service users who may be prone to wandering. Service users personal accommodation was viewed, which was cleanly decorated and demonstrated where service users had personalised their room. Furniture is of a domestic style and is in good order. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 15 The home was clean, comfortable, tidy and well presented and there were no unpleasant odours. Designate cleaning staff are employed who attend specific training in relation to their roles. Aids and adaptations are provided for residents who require them, they are serviced regularly and the staff receive training to use any equipment as necessary. The temperatures of radiators is controlled and water temperature restrictors are fitted to water outlets to minimise risks of scalding and water and electrical systems are tested although records of these were not fully viewed on this occasion. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 16 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, 30 Recruitment procedures are in place and the staff receive induction when commencing work at the home. There are sufficient numbers of staff, appropriately deployed to allow them to care for the residents. EVIDENCE: The service users and representatives spoken with confirmed that the homes care staff met their individual care needs. Comments included: “Well, it is fine for me, you are well looked after here”. “You may have to wait a short while for a carer but nothing really”. “They do get busy but its what you would expect, they are very good overall”. The staff records viewed were well maintained and clearly evidenced that appropriate recruitment procedures had been followed overall. The staff members spoken with confirmed that they had received induction upon commencing work at the home. At least 50 of the homes staff have attained NVQ training to level 2 and others have been identified to attend this training. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 17 Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 18 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, 38 Service users are supported to express their views regarding life within the home and the care provided. The staff are trained to meet service users care needs although minor adjustments are needed. The premises are very well maintained overall although not adequately risk assessed. EVIDENCE: A qualified and experienced manager is in charge of the home and the service users and staff members spoken with were satisfied with the overall management approach. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 19 Residents meetings are held and records of these are maintained. Quality satisfaction questionnaires are sent to service users and their representatives and action is taken as required. The home is very well maintained and a risk assessment of the premises has previously been undertaken although this could not be located during the visit. The staff attend a comprehensive amount of statutory training, which is ongoing although one minor adjustment is required to provide dementia awareness training. Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 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 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X X 3 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 X X X 2 Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 21 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 14(c) 15(1)(2) Requirement Timescale for action 30/11/05 2 3 OP38 OP38 18(1)(c) (i) 12(1) 13(4) Care records must demonstrate how each service users care needs are met and where service users are party to the devising of the care plan. staff must attend training 30/01/06 regarding Dementia awareness. A comprehensive risk 30/01/06 assessment of the premises must be completed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Whitefriars DS0000002476.V254631.R01.S.doc Version 5.0 Page 23 - 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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