Inspection on 18/07/06 for Whitefriars Nursing and Residential Home

This inspection was carried out on 18th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Nursing and... 20/09/07

Whitefriars Nursing and... 03/10/05

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Whitefriars Nursing and Residential Home 9 Dormers Wells Lane Southall Middlesex UB1 3HU Lead Inspector Ms Jean Bovell Key Unannounced Inspection 18th July 2006 11:00 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 Nursing and Residential Home DS0000064702.V300850.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 Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitefriars Nursing and Residential Home Address 9 Dormers Wells Lane Southall Middlesex UB1 3HU 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) 020 8574 0156 020 8574 1487 Caring Consultancy Ltd Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0) of places Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate service users who are medically or chronically sick over the age of 40 years. As agreed on 21st February 2006, one named service user with Dementia can be accommodated within the home. This is approved for as long as there is no deterioration of the service user that affects the well-being of any other person living at the home. The home must advise CSCI when the service user no longer resides at the home. 3rd October 2005 Date of last inspection Brief Description of the Service: Whitefriars is a nursing home registered to provide care for twenty-eight service users. It is privately owned and the Registered Provider is Caring Consultancy Limited. The home is a detached house located within a mile of Southall Broadway and is accessible to shops and public transport links. There is parking in front of the home and on the main road. There are eighteen single bedrooms and five double bedrooms situated over two floors. There is a large lounge with access to a patio and enclosed attractive rear garden. The dining room looks out onto the front garden. The staff employed at the home includes registered nurses, care assistants and ancillary workers. Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out between 11am and 4pm on 18th July 2006. The Manager Designate, three registered nurses, four health care assistants, an activities organiser, three ancillary staff and twenty-seven service users were present. During the course of the inspection: The home’s records, policies, procedures and documents were viewed. A tour of the building was undertaken and observations were made. The Inspector spoke to two registered nurses, one health care assistant, five service users and one relative. The requirements that were made at the last inspection and all key Standards were examined. The Manager Designate was co-operative and provided appropriate assistance throughout the inspection. What the service does well: The service users appeared appropriately dressed, well cared for and comfortable. Those who spoke to the Inspector said that they were satisfied with the service they received. There was an open, relaxed and friendly atmosphere and various visitors were observed meeting with service users in the lounge, garden and individual bedrooms. There were positive reports from a visitor in relation to the care that was being provided to a close relative. All health and safety records were satisfactory and indicated that the best interests of the service users were being protected. The overall environment within the home was safe, calm, homely and pleasant. Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 6 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. Whitefriars Nursing and Residential Home DS0000064702.V300850.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 Nursing and Residential Home DS0000064702.V300850.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. The separate needs of prospective service users are appropriately assessed and they receive written confirmation their separate assessed needs, prior to admission. Service users placed for intermediate care receive professional assistance in maximising their independence for being returned home. EVIDENCE: It was evidenced on service users files that were viewed at random that referrals were received from local authority social workers based in hospitals within Ealing and Hillingdon. Background information was submitted and the home initiated their own needs led assessments by visiting prospective service users, usually in hospitals. Social workers and medical professionals were Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 9 involved in the process of assessing separate healthcare, personal and social needs, and relatives were also invited to visit the home as part of this process. New service users receive confirmation that specific assessed needs will be met at the home and are placed on a trial basis of three months after which a review is convened. The Manager Designate confirmed that two beds were allocated for intermediate care and that the service included appropriate therapy from a physiotherapist. Whitefriars Nursing and Residential Home DS0000064702.V300850.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, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Separate health, personal and social needs are appropriately identified within care plans and the health care needs of the service users are being met satisfactorily. The home’s policy and procedures relating to medication are in place but none of the service users are able to administer their own medication. The dignity and privacy of the service users are being respected and specific wishes or requests relating to their death are documented. EVIDENCE: A number of care plans were viewed at random and it was evidenced that individual personal and healthcare needs were assessed and that social interests were identified. Appropriate action plans and set goals were put into place and risk assessments were carried out. Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 11 All care plans and risk assessments inspected were regularly reviewed. The Manager Designate reported that a general practitioner and physiotherapist visited the home on a weekly basis. There were interventions from tissue viability nurses and regular dental, optical and chiropody checks were arranged. None of the service users were suffering from pressure sores at the time of the inspection. A medication policy was in place and the storage, administration and disposal of medicines were satisfactory. Medication was being administered to all the service users at the home in a satisfactory manner. Nursing staff and health care assistants were observed interacting with service users and responding to their needs in a respectful manner, and knocked on bedroom doors prior to entering. Screens had been installed in all shared bedrooms and care staff confirmed that personal care tasks were carried out in privacy and that the dignity of the service users was at all times respected. The home’s policy and procedures on death and dying were in place and individual requests or wishes were recorded within care plans. Whitefriars Nursing and Residential Home DS0000064702.V300850.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. The service users are able to exercise personal choices and control over their lives and receive opportunities for participation in appropriate activities. Contact with relatives and friends is encouraged and facilitated. Varied and nutritional meals are being provided to the service users. EVIDENCE: The social interests of the service were reflected within care plans viewed and the Acting Manager reported that two part-time activities co-ordinators were employed at the home. It was indicated on the activities sheet that a physiotherapist visited the home each week. A Catholic priest delivered Holy Communion on a fortnightly basis and a Church of England Vicar also visited regularly. Hairdressing, manicures and movies were also featured. The Manager Designate confirmed that dial-aride transport was used for organised visits to a local park. Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 13 On the day of the inspection an activities co-ordinator was observed in the lounge engaging in separate activities with service users such as board games and drawing. Service users were also observed watching television, resting and reading. Others met with visitors - in the lounge, garden or within their separate bedrooms. An open visiting policy is in operation at the home and there were a number of visitors at the home during the inspection. The Inspector was informed by the Manager Designate that service users received choice in relation to meals, when they got up on mornings/retired at night, clothing, activities and meals. They were free to move freely around the home and were able to decide whether to have meals in their bedrooms or eat with others in the lounge or dining room. There are separate locks on all bedroom doors and service users are able to bring personal possessions into the home such as television sets, music systems, photographs and small items of furniture. The home employs a cook and wholesome and varied meals including cultural options, were reflected on the menus. Whitefriars Nursing and Residential Home DS0000064702.V300850.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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints policy is in place but the complaints procedure is not satisfactorily written. The service users are being protected from abuse. EVIDENCE: Although the complaints policy was in place, the stages of investigations were not clearly defined within the complaints procedure and CSCI details had not been updated. It was indicated in the complaint’s book that one complaint was made to the home following the last inspection and was satisfactorily investigated and resolved. The home’s policy and procedures on health and safety were satisfactory and a health and safety poster was on display. The Manager Designate reported that staff training on health and safety was scheduled to take place on 5th and 12th August 2006. Whitefriars Nursing and Residential Home DS0000064702.V300850.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 adequate. This judgement has been made using available evidence including a visit to this service. The overall environment is safe, clean and hygienic but specific areas are not being satisfactorily maintained. EVIDENCE: The ground floor of the home is spacious, comfortably furnished and suitable for shared or individual activity. The garden was well maintained and accessible to wheelchair users. There were no issues regarding the laundry. The home was essentially clean and hygienic and there were no unpleasant odours. Nonetheless, the area around the window/sill in the kitchen needed cleaning, the hallway on the first floor required decoration and there were no soap or hand towels in a toilet/hand washing facility on the ground floor. Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 16 The overall environment within the home was safe and pleasant. Whitefriars Nursing and Residential Home DS0000064702.V300850.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. The staffing levels at the home are adequate and appropriate training is being delivered to all care staff. Nearly 50 of permanent health care assistants have achieved or have commenced training on the national vocational qualification in levels 2 or 3. The recruitment policy and procedures are satisfactory. EVIDENCE: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager Designate confirmed that care staff employed at the home included seven permanent registered nurses, eleven permanent health care assistants, five regular bank registered nurses and four regular bank health care assistants. There were also two activities co-ordinators and ancillary staff including a cook, kitchen assistant, handyman and laundress. It was reflected on the staff rota that two registered nurses and five health care assistants were on duty during the peak morning period and two registered nurses and three health care assistants covered the afternoon/early Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 18 evening shifts. One registered nurse and two health care assistants covered waking duty at night. Individual staff training programmes were in place and it was indicated that new staff members had been inducted and that subsequent training delivered included manual handling, wound management, catherisation, basic food hygiene and dementia awareness. Training on health and safety, manual handling, first aid, and fire safety was scheduled for delivery in July and August 2006. The Inspector was informed by the Manager Designate that two health care assistants had achieved levels 2 and 3 NVQ, and that three health care assistants had commenced NVQ training. Several recruitment files were inspected at random and were found to contain all the required documents including: CRB disclosure certificates, photoidentification, application forms, references and signed contracts/statement of terms and conditions. Members of the care and nursing staff who spoke to the Inspector expressed satisfaction with the training and support they received at the home and were observed being competent and attentive in meeting the needs of the service users. Whitefriars Nursing and Residential Home DS0000064702.V300850.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. The Manager Designate is appropriately trained and satisfactory systems are in place for self-monitoring. The health, safety and welfare of the service users are being protected but environmental risk assessments have not been undertaken. EVIDENCE: The Manager Designate is a registered nurse and was previously the Deputy Manager. She has received all the mandatory training and is currently being trained on the Registered Managers Award. Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 20 Nursing and health care staff who spoke to the Inspector reported that the Manager Designate was approachable and provided practical assistance whenever or wherever it was required. The Manager Designate confirmed that new systems for self-monitoring were being put into place and the process of establishing the views of service users, relatives and stakeholders would commence within the coming months. It was indicated on documents viewed that appropriate quality assurance exercises had previously been undertaken. The home does not hold financial responsibility for any of the service users. Environmental risk assessments had not been undertaken but all health and safety checks were up-to-date. These included gas maintenance, portable electrical appliances, emergency lighting, fire drills, fire safety and legionella tests. Window restrictors were in good working order. Whitefriars Nursing and Residential Home DS0000064702.V300850.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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 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 2 Whitefriars Nursing and Residential Home DS0000064702.V300850.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. 1 Standard OP16 Regulation 22(2) Requirement The Registered Person must ensure that that the complaints procedure is reviewed and updated to include the stages/process of investigations and details of the CSCI. The Registered Person must ensure all areas within the kitchen are kept clean. The Registered Person must ensure that the hallways are reasonably decorated. The Registered Person must ensure that soap and hand towels are available within all toilet/hand washing facilities at all times. The Registered Person must ensure that environmental risk assessments are carried out in relation to identified hazardous areas within the home. Timescale for action 30/08/06 1 2 3 OP19 23(2)(d) 23(2)(d) 13(4)(c) 15/08/06 30/09/06 15/08/06 OP19 OP26 4 OP38 13(4)(c) 30/08/06 Whitefriars Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 23 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 Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 Nursing and Residential Home DS0000064702.V300850.R01.S.doc Version 5.2 Page 25 - 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!