Inspection on 20/09/07 for Whitefriars Nursing and Residential Home

This inspection was carried out on 20th September 2007.

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

Other inspections for this house

Whitefriars Nursing and... 18/07/06

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 Unannounced Inspection 20th September 2007 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.V345474.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.V345474.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 Manager post vacant 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.V345474.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. 18th July 2006 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. The fees are currently between £465 and £575 weekly. Whitefriars Nursing and Residential Home DS0000064702.V345474.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 11:00 am and 5:30 pm on 20th September 2007. During the course of the inspection The Registered Provider, Acting Manager, three Registered General Nurses, two Health Care Assistants, ten residents and four relatives were spoken with. The home’s records, documents, policies and procedures were viewed. A tour of the building was undertaken and observations were made. The requirements that were made at the last inspection and all key Standards were examined. The Registered Provider and Acting Manager were co-operative and provided appropriate assistance throughout the inspection. What the service does well: The needs of prospective residents are fully assessed prior to admission and separate cultural, language, religious and dietary needs are being met satisfactorily. Care plans and related risk assessments are being appropriately undertaken and regularly reviewed. All health and safety records are up to date. Residents appeared appropriately dressed, well cared for and comfortable. Residents and relatives that were spoken with expressed satisfaction with the overall standard of care provided but were particularly complimentary about the food. The environment was calm and homely. Whitefriars Nursing and Residential Home DS0000064702.V345474.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. The summary of this inspection report can be made available in other formats on request. Whitefriars Nursing and Residential Home DS0000064702.V345474.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.V345474.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): 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 personal records relating to residents were inspected at random. It was reflected that people’s needs had been appropriately assessed prior to admission and that they received written confirmation that separate identified needs would be met at the home. EVIDENCE: A number of personal records were examined at random. It was evidenced that assessments that had been carried out by placing authorities and relevant health care professionals were submitted at the point of referral. Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 9 Copies of needs led assessments that were subsequently undertaken by the home were also on file. It was indicated that prospective residents, relatives, social workers and health care professionals were involved in the process of determining the suitability of the home in meeting separate identified needs. Confirmation that specific assessed needs would be met at the home is included within contracts/statement of terms and conditions which were appropriately signed. Intermediate care is not being provided at the home. Whitefriars Nursing and Residential Home DS0000064702.V345474.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A number of care plans were viewed and reflected that the changing needs of people were being regularly assessed and that separate health care needs are being met satisfactorily. The policy on Medication was in place. People that were spoken with confirmed that their privacy and dignity were being respected. EVIDENCE: Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 11 All care plans viewed were indicative of changing personal, healthcare and social needs of residents being assessed and actions and set goals were in place. Individual risk assessments such as moving and handling, falls, pressures sores and fire had been carried out. Care Plans and risk assessments were regularly reviewed. The separate health care needs of residents were identified within care plans and indicated that people received access to appropriate healthcare professionals as required. They were accompanied during medical appointments and weight charts were reflective of people being weighed on a monthly basis. Pressure mattresses were provided to everyone but the Acting Manager confirmed, that at the time of the inspection, none of the residents had developed pressure sores. The Inspector was informed by the Acting Manager that people who use the service required assistance with personal care and that tasks were carried out in privacy within bedrooms or bathrooms. Policies and Procedures on Privacy and Dignity were in place. Registered Nurses and care workers were observed interacting with people in a respectful manner and knocked on bedroom doors prior to entering. Residents who were spoken with confirmed that their privacy and dignity were being respected.. Medicines were securely stored and accurately documented and signed. The records indicated that a pharmacist visited the home and carried out medication checks every three months. The Acting Manager confirmed that Registered Nurses were responsible for administering medicines and that none of the residents had capacity to selfadminister their medication. The home’s policy on medication was in place and comprehensive. Whitefriars Nursing and Residential Home DS0000064702.V345474.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s social and cultural needs are being met appropriately and they are able to make choices in relation to their daily living routines. Contact with relatives and/or friends is encouraged and facilitated. Varied and nutritional meal choices are being provided. EVIDENCE: Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 13 The Activities Co-ordinator was spoken with and confirmed that Roman Catholic and Church of England Priests visited the home alternatively every month. People received Holy Communion and listened to Songs of Praise. Religious festivals such as Ramadan, Ede and Duwali were celebrated. Residents were able to view culturally appropriate DVDs and a significant number of care staff was able to meet specific language needs. Weekly activities programmes were in place and reflected that a piano and guitar player visited the home every two weeks and two months respectively. Organised indoor and outdoor activities included arts and crafts, musical exercise, gardening, meals out, shopping trips and walks in local parks. Residents’ paintings and drawings were on display and people were observed chatting with relatives and/or sitting in communal areas and also the garden. Others were resting, watching television or reading in separate bedrooms. A resident’s birthday was celebrated during the course of the inspection. An open visiting policy was in place and several relatives visited the home at the time of the inspection. The Acting Manager confirmed that people were able to make decisions regarding meals, activities, when they retired at night, got out of bed on mornings, what they wore each day, hairstyles and make-up. People moved freely around the home and/or garden and separate interests and choices were reflected in personalised bedrooms. A variety of fresh, frozen and dried foods were stored in the kitchen. The home employs three catering staff and the menus were reflective of varied and wholesome meal options that included cultural choices. Regular drinks and snacks are provided and people can choose whether to eat in the dining room, main lounge or have meals delivered to their separate bedrooms. Residents that were spoken with expressed satisfaction with the quality and quantity of food they received. Whitefriars Nursing and Residential Home DS0000064702.V345474.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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is satisfactorily detailed and policies and procedures on abuse are in place. However, a complaint has been passed to the Safeguarding Adults Team and has not yet been resolved. EVIDENCE: The complaints procedure was in place, clearly detailed and accessible to residents, relatives, advocates and/or friends. The complaints folder was viewed and indicated that two complaints had been made following the last inspection. One complaint had been investigated by the home and satisfactorily resolved. The other was reported to the Safeguarding Adults Team and is currently being investigated. Policies and procedures on Adult Protection were in place and the records were reflective of staff training on the Protection of Vulnerable Adults being delivered. However, a recent safeguarding adults issue currently under investigation would appear to indicate that the Local Authority Safeguarding Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 15 Adults procedure was not followed. As a result of this, refresher POVA training has been arranged for all care staff. The Acting Manager confirmed that the home held no financial responsibility for residents. Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the environment is safe and homely but specific areas within the kitchen are not being satisfactorily maintained. A programme for refurbishment of the home is in place. EVIDENCE: A ‘Building Audit’ detailing a programme of refurbishment that included the upgrading of bathrooms and toilets was in place. The Inspector was informed Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 17 by the Registered Provider that the home had received a grant from the local Council and that all works were scheduled for completion in February 2008. The communal areas are spacious, comfortably furnished and suitable for shared or individual activity. However, redecoration was required particularly on the upper floors and floor coverings needed cleaning or replacing. Specific areas within the kitchen were not satisfactorily clean. These were windows and sills, outer and underneath cupboards and the pantry floor. Cooked food lay uncovered in the refrigerator and separate meals that had been dished up in advance of supper were left uncovered on kitchen surfaces. The garden was well maintained and accessible to residents and their relatives. There were no issues regarding the laundry. The environment was safe, calm and homely. Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels at the home are adequate and care staff members are appropriately trained and qualified for meeting the needs of people who use the service. However, it was reported that residents are not at all times being supervised and individual requests for assistance with personal care may receive prompt attention. Staff files were inspected at random and reflected that the home’s recruitment policy and procedures were satisfactory. EVIDENCE: The Registered Provider confirmed that Six Registered Nurses and twelve Care Assistants were employed at the home. There were also, three catering staff, two cleaners and a gardener/handyman. Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 19 The rota reflected that two Registered Nurses and five Care Assistants were on shift during waking hours and one Registered Nurse and two Care Assistants covered waking duty at night. The records indicated that newly employed care staff received induction training and that subsequent mandatory training had been delivered. Refresher training on Protection of Vulnerable Adults and Moving and Handling is being delivered in October/November 2007. A number of staff recruitment files were viewed at random and contained all required documents. The Inspector was informed by the Registered Provider that six Care Assistants had achieved level 2 National Vocational Qualification in Health and Social Care and six Care Assistants had commenced Level 3 NVQ training. The ratio of care staff to residents appeared adequate at the time of the inspection. However, a relative reported that people were often left unsupervised in the main lounge. It was also revealed by a resident that he/she had waiting for several hours for a response to a request for personal assistance. This was discussed with the Acting Manager. Immediate appropriate action was taken and the resident’s needs were attended to. Attention must be paid to having effective deployment of staff to ensure that people’s needs are promptly met. Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being satisfactorily run and the records indicated that effective quality assurance has been carried out. Health and safety records viewed were up-to-date and reflected that the welfare of residents was being protected. EVIDENCE: Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 21 The acting Manager is a Registered Nurse who has been employed at the home for several years. She was previously the Deputy Manager. Care Assistants and Registered General Nurses that were spoken with reported that the Acting Manager was friendly, approachable and supportive. There was documented evidence that effective quality assurance had been undertaken and appropriately summarised. The home does not hold any financial responsibility for residents. A Health and Safety poster was on display at the home. Health and safety records were viewed and indicated that checks including fire alarms, portable appliances, water temperature and gas maintenance were up-to-date. Tests for Legionella had been undertaken and fire drills were regularly carried out. The records indicated that care staff had received training on moving and handling, fire safety, infection control and Health and Safety. Environmental risk assessments were in place. Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 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 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23(2)(d) Requirement The Registered Person must ensure that hallways on all floors are reasonably decorated. This is being restated from the last inspection. Previous timescale 30/09/07. The Registered Person must make sure that stored cooked meals are covered to ensure that risks to the health of residents are being avoided. The Registered Person must ensure all areas within the kitchen are kept clean. This is being restated from the last inspection. Previous timescale 15/08/06. The Registered Person must make sure that residents receive personal assistance as required to avoid unnecessary risks to their health and welfare. The Registered Person must make sure that people sitting in the main lounge are supervised at all times to ensure that their needs are being met. Timescale for action 20/09/07 2. OP26 13(4)(c) 10/10/07 3. OP26 23(2)(d) 10/10/07 4. OP27 13(4)(c) 10/10/07 5. OP27 13(4)(b) 10/10/07 Whitefriars Nursing and Residential Home DS0000064702.V345474.R01.S.doc Version 5.2 Page 24 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.V345474.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V345474.R01.S.doc Version 5.2 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. 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