Inspection on 03/10/05 for Whitefriars Nursing and Residential Home

This inspection was carried out on 3rd 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 Nursing and... 20/09/07

Whitefriars Nursing and... 18/07/06

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 3rd October 2005 11:45 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.V251879.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 Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 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 Ms Urvasee Shersing 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.V251879.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Either elderly medically sick of either sex aged 60 and above or Young chronic sick of either sex over the age of 40 3 beds in the home are dual registered with Local Authority Date of last inspection 19th April and 10th May 2005 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.V251879.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. It was carried out between 11.45 am and 4.30 pm on 3rd October 2005. The Registered Manager, two registered nurses, four care assistants and 24 service users were present. The Inspector was informed that two service users had been admitted to hospital. Four relatives visited the home during the course of the inspection. The Inspector spoke to three care support staff members, ten service users and four relatives. A tour was undertaken throughout the building. Records, documents and policies were examined, and observations were made. The Registered Manager was co-operative and assisted the Inspector throughout the inspection. The home was essentially well run and the environment was safe, calm and comfortable. What the service does well: There have been marked improvements within the home since the last inspection. The Inspector was advised that an activities co-ordinator had been recruited and there were weekly visits from a physiotherapist and also a chiropodist. The old water tank had been replaced and the service users were provided with new adjustable beds. The home has maintained a permanent staff group of many years. The Inspector held discussions with three staff members who reported that the Registered Manager was approachable and supportive. The service users appeared appropriately dressed and well cared for. Those who spoke to the inspector indicated that they were, on the whole, happy with the standard of care provided at the home. Visiting relatives expressed similar views. The records, policies and procedures that were in place were essentially satisfactory. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 6 The home was organised and focused on generally improving standards that are intended to better the quality of care being provided to the service users. 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.V251879.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 Nursing and Residential Home DS0000064702.V251879.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): 2, 5 and 6. The home’s contract/statement of terms and conditions is satisfactory and is signed by new service users at the point of admission. Relatives and friends are involved in initially assessing the home’s capacity to meet the specific needs of prospective service users. EVIDENCE: Individually signed copies of the home’s contract/statement of terms in relation to new service users were viewed at the time of the inspection and all were found to be satisfactory. The Registered Manager confirmed that interested relatives and friends were required to participate in the assessment process in relation to prospective service users. This involved visiting the home, making relevant enquiries and generally obtaining assurances that the home would be able to meet specific needs. The home does not provide intermediate care. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 9 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): 8, 9 and 10. The health care needs of the service users are appropriately met and their privacy is respected. EVIDENCE: The Inspector was informed that GP appointments were made when required but home’s GP also visited each week and carried out reviews on two or three service users. A Chiropodist who was present during the inspection visited the home each week. There were also weekly visits from a Physiotherapist. Dental and Optical care were arranged when necessary. The Registered Manager reported that an appointment had been made for a service user to be seen by an Audiologist. The home’s medication policy was in place and medication training had been delivered to the care support staff team. The storage and administration of medication were seen to be satisfactory. None of the service users were self administering their medication at the time of the inspection. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 10 Recordings of regular staff supervision were not available at the time of the inspection. Separate locks had been fitted onto all service users’ bedroom doors, shared bedrooms contained dividing screens and staff members were observed to knock on service users’ bedroom doors prior to entering. The Registered Manager reported that assistance with personal care was carried out in privacy within bedrooms or bathrooms. Service users who spoke to the Inspector indicated that their privacy and dignity were respected at the home. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 11 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 and 14. The home has an open visiting policy and contact with relatives and friends are encouraged and facilitated. Service users are able to exercise choice and make individual decisions regarding their daily living routines. EVIDENCE: The Inspector was advised that service users were encouraged to maintain their independence in relation to daily living routines. They were offered choice of meals and whether they wished to have meals served in their bedrooms. Service users decided what they wore and when they got up in the mornings or retired at night. They were also able to make decisions in relation to activities such as leaving the home independently, sitting in the lounge or staying in their bedrooms. Service users were observed watching television, reading, resting or meeting with relatives in their individual bedrooms. Others sat quietly, watched television or chatted with other service user or relatives in the lounge. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 12 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 17. The home’s complaints procedure is satisfactory and legal rights of the service users are protected. EVIDENCE: The home’s complaint’s procedure is clearly stated and accessible to the service users and their relatives. No complaints have been made to the home since the last inspection. The Registered Manager confirmed that service users legal rights were protected at home and that one service user had recently received assistance with accessing a solicitor. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 13 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): 20, 21, 22, 23, 24 and 25. The communal areas within the home are spacious and appropriate for shared and individual activities. The bedrooms are personalized and toilet and bathroom facilities are adequate for meeting the needs of the service users. Suitable aids and adaptations are in place. EVIDENCE: The home’s spacious lounge and medium sized dining room are comfortably furnished and suitable for shared or individual activities. The large surrounding gardens are accessible to wheelchair users. The toilet and bathroom facilities are appropriate for meeting personal needs of the service users and aids and adaptations for providing additional assistance are in place. These include hoists, grab rails and raised toilet seats. A telephone line and a nurse call system are installed in each bedroom. There is Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 14 a passenger lift and service users were observed using wheelchairs, zimmer frames and walking sticks during the inspection. The service users bedrooms were viewed. All were suitably furnished and fitted, and reflected personal choices. The home was found to be pleasant, comfortable and safe. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 15 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 and 30. The staff employed at the home are appropriately trained and competent in meeting the needs of the service users. EVIDENCE: The home employs nineteen care support staff including seven Registered General Nurses. There are also two cooks, one assistant cook, two cleaners, one laundry person, one handyman and one activities co-ordinator. The Registered Manager reported that several members of the care support staff group had obtained NVQ 2 or 3 and three staff members had almost completed NVQ 2, training. It was indicated on the staff rota that two nurses and four care support workers were on duty in the morning, and two nurses and three care support workers covered the afternoon/evening shifts. Two sleeping care support staff members and one waking nurse were on duty at night. Training certificates viewed confirmed that induction training was delivered to new members of staff and that subsequent training included, fire safety, moving and handling, medication, food hygiene, protection of vulnerable adults, wound care and male catherization. An appropriate number of staff were on duty during the inspection and they were observed to respond competently to the needs of the service users. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 16 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, 32, 33, 35, 36 and 37. The Registered Manager is appropriately qualified and experienced and the safety and welfare of the service users are essentially protected within the home. However, records relating to the water temperature and regular supervision of care staff, were not available at the time of the inspection. EVIDENCE: The Inspector was advised that the Registered Manager had nine years managerial experience and held her current position for one year. She was a qualified Registered General Nurse and Registered Nurse for Learning Disabilities. She had also received training in palative care and expected to complete an RMA course before the end of 2005. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 17 The Registered Manager confirmed that the home operated an open and flexible approach and ensured that the individual needs of the service users were met while promoting their independence. The Inspector was informed that the home did not deal with the financial affairs of the service users and that financial responsibility lay with relatives or local authorities. Recordings of regular staff supervision were not available at the time of the inspection. All records seen at the time of the inspection were satisfactory. Policies and procedures were in place and indicated that the safety and welfare of the service users were safeguarded at the home. Health and safety records such as legionella testing and checks in relation to fire safety, emergency lighting, portable appliances and gas and electricity maintenance, were up to date. However, records relating to water temperatures were not available. Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 18 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 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 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 3 18 X X 3 3 3 3 3 3 X STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 2 Whitefriars Nursing and Residential Home DS0000064702.V251879.R01.S.doc Version 5.0 Page 19 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 OP36 Regulation 18(2) Requirement The Registered Person must ensure that persons working at the care home are appropriately supervised. The Registered Person must ensure that any activities in which service users participate are so far as reasonably practicable free from avoidable risks. Timescale for action 15/12/05 2 OP38 13 (4)(b) 15/11/05 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.V251879.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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.V251879.R01.S.doc Version 5.0 Page 21 - 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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