Inspection on 26/06/07 for Whitegates Private Nursing Home

This inspection was carried out on 26th June 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 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

Whitegates Private Nursing Home 12/09/05

Whitegates Private Nursing Home 16/06/05

Whitegates Private Nursing Home 27/09/04

Whitegates Private Nursing Home 02/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Whitegates Private Nursing Home Condor Road Laleham Staines Middlesex TW18 1UG Lead Inspector Susan McBriarty Unannounced Inspection 26th June 2007 10:30 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 Whitegates Private Nursing Home DS0000017651.V338381.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. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitegates Private Nursing Home Address Condor Road Laleham Staines Middlesex TW18 1UG 01784 441287 01784 466826 info@whitegates-nursinghome.co.uk 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) Whitegates Private Nursing Home Ltd Mrs Elizabeth Mendelssohn Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. In the case of this service residents may be admitted from the age of 60 years. In the event of one of the named service users vacating the shared room, that room shall revert back to single occupancy use. 12th September 2005 Date of last inspection Brief Description of the Service: Whitegates is a privately owned nursing home which provides care for 39 residents who are 65 years and older. The home is situated in Laleham near Staines and close to the shopping centre and major roads and the river. The home provides 37 single bedrooms and one bedroom being shared with agreement from the commission. All the bedrooms are provided with a wash hand basin. Bathroom and toilet facilities are shared. The home is set over two floors with access to the first floor by stairs or lift. Each floor has a small dining area and a large lounge and conservatory are provided on the ground floor. The garden is accessible and provides a seating area for use during good weather. In 2007 the home was charging a flat rate fee weekly fee of £750. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over six and a half (6.5) hours, commencing at 10:30am and ending at 4:00pm. Ms Susan McBriarty, Regulation Inspector, carried out the visit. The manager was available throughout the inspection and a senior member of staff also assisted the commission. The inspection took into account the Annual Quality Assurance Audit (AQAA) required by the commission to be completed by the home, records held at the home including residents files, staff personnel files, training, medication administration and care records. The inspector made observations of interactions between staff and residents during the visit and spoke with some of the residents and staff. Sixteen comment cards were received from health and social care professionals, relatives and residents. A number of health and social care surveys had been completed by relatives, as the same questions were not asked this had affected some of the feedback. What the service does well: What has improved since the last inspection? The requirements made during the inspection of the 12th September 2005 had been met confirming that the home ensures safe recruitment practices. The home had started work on improving the care plans to ensure they included how the people who use the service prefer to receive their care. This included their preferred morning and evening routine. The commission were informed that more permanent staff had been employed to work at the home in order to reduce the use of agency staff. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 6 What they could do better: Four requirements and two recommendations have been made following the visit to the home. One risk assessment about a resident taking their own medication could not been found and confirmation is needed to make sure that risk assessments are completed and available. This will make sure that the home follows safe practice. A recommendation is made that the home review the activities provided to take into account the range of assessed needs of the people who use the service including their ability or wish to access activities. This will make sure that all the residents have the opportunity to access an activity they prefer if they want to. A requirement is made for the home to devise and implement a policy and procedure to safeguard adults and revise the whistle blowing policy and procedure to make sure that policy supports the practice of the home. A recommendation is made that the training records held by the home include all the training carried out by all members of staff. This will assist the home with easy access to information and planning. The home needs to devise and implement a quality assurance system for the home so they can confirm to residents, their relatives and stakeholders how well the home is doing and what action might need to be taken to further develop or improve the service. A number of policies and procedures held by the home need to be reviewed and where necessary revised to make sure they are up to date and have taken into account any legislative changes since they were last reviewed. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 7 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. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 8 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 Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 9 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): Standard 3 was assessed. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives can be confident that no resident moves into the home until an assessment of needs has been completed and been assured that these will be met. EVIDENCE: A number of resident files were sampled. Where the resident had been at the home for some time the assessment information was held in a separate file. Those sampled confirmed that an assessment had been completed before the resident moved to the home. Written feedback from seven (7) relatives and residents and three (3) relatives spoken with said that an assessment had taken place and one relative made further comment saying their views had been taken into account. Feedback from one person identified a problem with the Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 10 assessment process and was concerned to ensure the home did not take people whose needs they could not meet. On taking into account the information received by the commission and the documents and records looked at during this visit and in discussion with the manager it was concluded that home seeks the information necessary to ensure that they are able to meet the needs of those residents offered a placement. The AQAA received from the home stated that visits are made to the prospective residents home or to the hospital to carry out the assessments necessary. This was confirmed in the feedback received from residents and relatives. The information received from relatives indicated that they found gaining the information they needed about a home and what it does difficult to find. We informed some of the relatives spoken with of the commission’s web site where copies of inspection reports can be gained, the home can also be asked for sight of or a copy of the last published inspection report. The home also has a statement of purpose and service user guide that set out what the home does or does not do and is accessible on request. The commission did not view the home’s statement of purpose and or service user guide during this visit. It might benefit the home to make sure all prospective residents and their relatives are informed of these matters and offer copies or sight of the documents during visits to the home. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of people who use the service are met. The policy and practice of the home regarding giving medication support and protect the residents. EVIDENCE: A number of care plans were sampled. The commission were informed that the care plans in use by the home were being further developed to show the personal preferences of the residents. A number of those sampled confirmed this for example one made clear the preferred morning routine and night routine of a resident including whether they wanted to have their bedroom door left open a little at night. The care plans made clear the needs of the people using the service including their health needs and whether access was also required to a dentist or optician. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 12 The same system allowed for risk assessments to be documented and recorded including the action taken to reduce any risks to the resident for example the use of bed rails. The recommendation made during the inspection of the 12th September 2005 had been met. The care plans and risk assessments identified that reviews had taken place and were dated, signed and any change in need had been identified and acted upon. One relative and one health professional said that the home monitors the care plans well and seek advice as necessary. One relative said they were pleased at the routine monitoring carried out at the home. Feedback from residents and relatives varied as to how they were included in the review process. Some said they were asked but had not seen the final document, some said they had been included. The home would benefit from clearly documenting who was involved in the review and where possible ask for their signature or indicate that involvement was not possible or not preferred. Of the thirty nine (39) people living at the home thirty eight (38) were white British and one (1) from another white background. Thirty four (34) of the residents were Christian and remaining five (5) were not recorded. Thirty one (31) of the residents were female and eight (8) were male. The AQAA received by the commission stated that all the staff working at the home declined to give their ethnicity as part of the inspection process, forty nine (49) staff were female and four (4) were male. Information about pressure care needs had been clearly recorded and documented including the progress of healing. Fluid and bowel charts were in use as necessary and according to the needs of the resident. In addition turning charts documented and recorded each turn and had been signed and dated by the member of staff. The AQAA provided by the home said that the tissue viability nurse is called in as required by any resident. The daily records kept by the home were also sampled. The records had been completed appropriately and signed and dated by the person who carried out the task necessary. The records also identified when the doctor or other health professional had seen the resident. The AQAA provided by the home confirmed that the continence nurse visits regularly, eye tests are carried out and hearing tests are carried out by the Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 13 local hospital. A chiropodist visits every 6 to 8 weeks. One of the relatives spoken with said the home makes sure that where the resident is entitled the NHS provides chiropody. The doctor visits the home weekly and the home makes sure the doctor receives the information they need before they attend the home. The doctor will also visit as needed during the week. The doctor was spoken with briefly during this visit and the regular visits to the home were confirmed. The doctor told the commission that he was called out appropriately. All of the feedback received by the commission confirmed that residents privacy and dignity were respected, one made comment that staff always make sure that doors are closed and privacy was respected. The medication policy and procedure used by the home was looked at and included instruction on disposal. The requirement form the inspection of the 12th September 2005 had been met. The manager said that only nurse qualified members of staff were able to give medication. A number of medication records were checked; the records seen covered the last four weeks. No errors were found in confirming medication was given. Signature samples of those members of staff able to give medication were in place and needed some minor updating to remove those no longer working at the home. Photographs of each of the residents had been provided to help reduce the risk of error. The cupboard where medication is stored was looked at and medication was seen to be stored appropriately. The controlled drug book was viewed and had been completed and set out what was received and who for. One page needed change during the visit to confirm what the medication was the record referred to, the remaining information about this matter had been completed in full and there was no confusion but a matter of confirming the usual good practice seen elsewhere in the same records. One risk assessment for a resident to be able to take his or her own medication could not be located. The manager was clear that it had been completed and signed by the doctor. A requirement was made for the home to confirm in writing to the commission that the risk assessment is in place. The manager said that training for the qualified nurse staff was provided on a regular basis, within six months for new staff and there after annually. Please also see the staffing section of this report. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 14 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): Standards 12,13,14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social, cultural, leisure and recreational needs of the people who live at the home including maintaining contact with their family were met. Some work was needed to confirm that the activities provided took into account the range of assessed needs of the residents. The meals provided by the home were varied and met the assessed needs of the residents. EVIDENCE: The care plans sampled also set out preferred activities of the residents. These included reading, watching television as well as going out. A separate record had been kept of any activity the resident had taken part in. The record confirmed the activity and the date. On the day of the visit a game of bingo was taking place and a number of the residents were taking part. The home had kept a file of the activities that had previously taken place including wine and cheese parties and pantomimes as well as a copy of the monthly list of activities due to take place that was provided to residents. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 15 Feedback from six (6) residents and relatives varied, four (4) said activities were always available, one (1) usually and one (1) sometimes. One said I do not always get the information about the activities, another said they seem to be provided mostly for those that can go out. One relative said it would be good if one to one activities could be provided to those who cannot take part or prefer not to be in a group. Other comments included it would help if the home provided an internal newsletter or encouraged volunteers and residents to participate /organise activities and one said they were being assessed and there was not a lot to do. The home had an activities coordinator in post and the AQAA said that the activities and visits have been expanded. Feedback received by the commission said that the coordinator was very good. During the visit the commission noted that the home was providing for a number of people who were very frail and in some instances unwell and being cared for in their bedrooms. This information along with some of the comments received by the commission identified that the home was caring for people with a range of needs. A recommendation is made that the home review the activities available taking into account the assessed needs of the residents to ensure a system is in place to make sure information is provided to all residents, that the activities provided take into account the range of needs of the residents and whether other options might be preferred by those who cannot take part in a number of the activities provided. The manager said that relatives were able to visit the home at any time unless a resident said they did not wish to see them. Relatives were encouraged to attend any function provided at the home and were able to take meals with their family member if they wished. A number of relatives were observed coming and going to the home on the day of the visit and some agreed to speak to the commission and this has been noted in various parts of this report. The AQAA provided by the home stated that the provided a wholesome and nutritious diet with a choice of menus and special diets being available as required. The home said that residents are weighed monthly and advice taken from a dietician if necessary. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 16 Feedback from residents and relatives varied as a number of people had completed the forms meant for health professionals, care managers or others. Comments received said that 2 always liked the meals, 3 usually liked them, one said choice is given although this may be confusing sometimes for the resident, another said they felt the times of the meals seemed to fit in with the routine of the home rather than resident preference. One relative said the food was lovely. The manager told the commission that breakfast was provided at a time that suited the resident (from 8am onward), as was supper. The main meal of the day was served at 12 midday for those who needed assistance and about fifteen minutes later for those who were independent. During the visit a number of residents and relatives were spoken with and one issue re food was raised, that the meals are sometimes delayed and do not arrive at the time given. Observations made by the commission on the day saw that meals could be served in either of the dining areas or if preferred or required in the residents bedroom. The meal served had been cooked fresh that day at the home and was served hot and from between midday and 12:30pm. Several people visiting their relatives during meal times had chosen to eat at the home. The commission reviewed the reports provided by the Environmental Health officers who had visited the home in October 2005 and November 2006. The officers had looked at the provision of food at the home. Over the two visits carried out by the environmental health officer two matters received recommendations. The 2005 report asked the home to complete a hazard analysis and the 2006 report for the home to complete Safer Food for Better Business. The manager told the commission that they were seeking accreditation for the food provided at the home to show how well the home was doing to confirm that residents had the nutrition they needed provided in a safe and appetising way. Members of staff had completed food hygiene training to ensure they were aware of safe working practices when dealing with food. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service can be confident that they are listened to and concerns acted upon and that the practice of the home protects them from abuse. Some improvement was needed to make sure that the policy of the home confirmed the practice of the home regarding safeguarding. EVIDENCE: A complaint policy and procedure was in place and included a timescale for responses to be provided. The home had not yet had the opportunity to revise the recent change of address of the commission and the manager confirmed that this would be completed shortly. The AQAA received by the commission said that two complaints had been received in the last twelve months both had been responded to within the expected timescale. The outcome of the complaints had not been given in the AQAA; the manager told the commission that neither complaint had been upheld. No safeguarding matters had been referred by the home or received by the commission since the last inspection of the 12th September 2005. Two members of staff spoken with were clear about what action they would take if they received an allegation of abuse or witnessed abuse and told the commission where the telephone number was for the local authority if they Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 18 had to make the call direct. A copy of the 2005 multi-agency safeguarding guidelines was held in the office. The management team of the home told the commission that they refer to the local authority multi-agency guidelines if an allegation were made. A policy had not been completed to confirm the practice of the home. A requirement is made that a policy and procedure be drawn up and implemented by the home that confirms support and process of the multiagency guidelines. The whistle blowing policy last reviewed by the home in 2001 was looked at and a requirement made to ensure that a statement is added to confirm what action would be taken if the whistle blower made an allegation of abuse to a resident. See also the management section of this report. The home also had a restraint policy and another for dealing with aggression and the manager confirmed that accredited training had not been provided and the home does not restrain the people living at the home. The manager removed both policies and procedures immediately. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 19 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): Standards 19 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the home live in a safe well-maintained environment that is kept clean and hygienic. EVIDENCE: A tour of the home took place and all of the communal areas and most of the bedrooms were seen. The bedrooms had been personalised containing photographs, pictures and other items owned by the resident. Specialised beds had been provided in each of the bedrooms included mattresses to reduce the risk of pressure areas. The bedrooms had a wash hand basin provided. One bedroom remains shared at the choice of the residents. The communal areas include two dining areas, three kitchens including the main kitchen, a lounge and conservatory. Stairs or lift reached the first floor. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 20 The building was no smoking and a smoking area had been made available at the rear of the building for visitors and members of staff. The communal lounge had been provided with a number of high back chairs and a television was available for use in the lounge and conservatory. Laundry was managed effectively taking into account the need for infection control and feedback received by the commission said that the laundry system was excellent. The garden was well laid to lawn and planting, a part time gardener was employed and was working on the day of the visit. The garden was accessible to residents and relatives had provided plants and benches as memorials. One paving slab was found to be loose and a potential trip hazard, this was reported for repair immediately. An infection control policy and procedure was in place and a member of staff told the commission about the procedures in place to make sure infection did not spread and that only when an infection was evidenced as being clear were those procedures lifted. Members of staff were seen washing their hands regularly and gel dispensers had been placed about the home for staff to use to further reduce the risk of infection. The maintenance person was spoken with during the visit who told the commission that he looked around the home to check what work was needed and looked at the reporting system used by the home to see what issues had been picked up by the staff. The commission were also told that bedrooms were redecorated for new residents and they had a choice in colour. Residents who had been living at the home for some time did not always want their bedroom redecorated and at times needed to be encouraged to allow painting to take place. The manager said that the home was able to purchase the equipment needed to make sure residents needs could be met safely and she felt fortunate that requests for purchase were never denied. Feedback from residents and relatives received by the commission confirmed that the home was normally kept fresh and clean; one comment received by the commission said that sometimes the shared kitchen areas and bedroom Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 21 tables were not clean. On the day of the visit all the communal areas were clean and hygienic and the bedrooms in the process of being cleaned. Where any issue was observed regarding the bedrooms it was confirmed that the cleaner had not yet entered that part of the home and the resident had only just left the bedroom. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 22 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): Standards 27,28,29 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures adequate members of staff are on duty and that they have the necessary training to carry out their job. The policy of the home makes sure that safe recruitment practices are followed. Some work was needed to make sure the home followed the recommendations made by the Criminal Record Bureau about recording and disposal of the documents. EVIDENCE: The home provided three (3) nurse qualified staff throughout the day and between six (6) and seven (7) care staff. At night one (1) nurse qualified member of staff was on duty with four (4) care staff. The home provides for up to thirty nine (39) residents. The AQAA received by the commission said that of the fifty three (53) members of staff fourteen (14) had completed a National Vocational Qualification (NVQ) to Level 2 or above and eight (8) were in the process of completing an NVQ to Level 2 or above. Eight (8) members of staff were nurse qualified. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 23 The manager told the commission that the home records the gender and ethnicity of the members of staff working at the home. As noted under the Health and personal care section of this report the staff had declined to give their ethnicity as part of the inspection process. A number of staff personnel files were looked at. A checklist had been provided at the front of each file showing what documents had been received by the home including application forms and references. Those sampled had all the information needed to confirm safe recruitment practice. A separate file held all the original Criminal Record Bureau (CRB) records. The commission sampled a number of these against the list of staff provided and confirmed that all those named had received a CRB check. The manager told the commission that where any issues had been identified in the CRB check she had met with the member of staff and discussed the matter. It would benefit the home to ensure that where a discussion had taken place that this be recorded and signed by both parties to confirm that the matter had been risk assessed by the home. The management of the home were fully aware of the Criminal Record Bureau guidelines regarding storage and destruction and the commission confirmed the same protocols. The requirement from the 12th September 2005 that all members of staff have a satisfactory CRB check had been met and the home were following safe recruitment practices. The home provided the commission with a document that set out the training provided at the home. Not all the training provided was recorded and the commission were told that document did not include external training received. It is recommended that the home have a system for recording all the training received to assist them to keep an overview of training provided and required. Certificates confirming the training received were held in the personnel files of members of staff including food hygiene, venepuncture and tissue viability. Notes from observed induction training including the outcome had also been made. The manager said the home was bringing in induction training based on Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 24 the common induction standard and they were looking at the best method for this home. Feedback from residents and relatives included: one (1) said staff always have the skills and experience needed, three (3) said they always receive the care and support needed and (1) usually, four (4) said the staff always listen and act on what they say. One relative said that they had a great admiration for the staff and managers as they work well together and were always cheerful and ready to help. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 25 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): Standards 31,33,35 and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run by a person competent to do so. Some improvement was necessary to make sure that the views of the residents and their relatives are listed to and acted upon. Improvement was needed to make sure that the policy and practice of the home support and protect the health and safety of the residents and members of staff. EVIDENCE: The manager of the home was nurse qualified and had thirty two (32) years experience of working in care homes including seven (7) years as the manager of this home. During the visit the manager talked about their relationship with the owner of the service and made clear that there were good lines of Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 26 accountability and that she was fully aware of her role and responsibility as manager. A quality assurance audit system was in place. The manager told the commission that she had not been using the system as they did not consider it adequate for this home and they are looking at an alternative system. This was confirmed in the information provided in the AQAA. Feedback from residents and relatives confirmed that they had not been asked what they thought about the services provided at the home. One thought it would be a good idea to have residents and relatives meetings to provide regular feedback as part of the running of the home. A requirement is made to ensure that a system of quality assurance is devised and implemented by the home that includes feedback from residents, relatives and stakeholders and the outcomes published and made known to residents and their relatives. The home does not assist residents with their finances. A system for keeping valuables was in place and a policy provided to support this practice. One entry was sampled that detailed what had been placed in the safe, the owner of the items, the date received by the home and signatures to confirm. The sample also showed the date collected and the signature of the resident confirming receipt. The AQAA received by the commission set out when safety checks had been completed for example the lift was services in March 2007,portable electric equipment in May 2007 and fire detection and fire fighting equipment was also checked in May 2007. These were confirmed with the manager and the member of staff responsible for the administration of the home. The commission sampled a number of records including the fire protection; completed on 25th May 2007 the certificate to confirm was seen. The maintenance file was viewed and contained the record of weekly checks including drain covers/fire alarm/patio furniture/roof space/ water temperature test and hoist inspections. The AQAA received by the commission showed that a number of policies and procedures had not been reviewed for some time including health and safety (2002), moving and handling (2002), fire safety (2002) and equal opportunities, diversity and anti oppressive practice (2001) and hygiene and food safety (2002). A requirement is made that the policies and procedures for the home are reviewed to make sure that they are up to date and take into account any legislative changes made. This will ensure that the people who Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 27 use the service and members of staff working at the home are supported and protected by the policy and practice of the home. Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 28 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 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 2 X 3 X X 2 Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 29 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 OP9 Regulation 13(2) Requirement The home must confirm in writing to the commission that any resident who takes and is responsible for their own medication has a documented risk assessment. A policy and procedure for safeguarding adults must be devised and implemented and a statement must be added to the whistle blowing policy to confirm the practice of the home regarding safeguarding matters. A policy and procedure for a quality assurance audit system must be devised and implemented to make sure that the views of residents, relatives and stakeholders is known, documented and any development or improvement agreed made known The policies and procedures of the home that have not been reviewed for some time including: health and safety, moving and handling, fire safety, equal opportunities and diversity and hygiene and food safety DS0000017651.V338381.R01.S.doc Timescale for action 13/07/07 2. OP18 13(6) 31/08/07 3. OP33 24 28/09/07 4. OP38 13(4)(6) 28/09/07 Whitegates Private Nursing Home Version 5.2 Page 30 must be reviewed and where necessary revised to make sure they are up to date and any legislative changes have been taken into account. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations It is recommended that a review of the activities provided take place taking into account the range of assessed needs at the home and the preferences of the residents to make sure their views and choices are taken into account. It is recommended that the home include all the training provided and received by members of staff to assist with easy access to records and planning arrangements. 2. OP30 Whitegates Private Nursing Home DS0000017651.V338381.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. 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