Inspection on 10/12/07 for Whiteley Village Care Centre

This inspection was carried out on 10th December 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

Whiteley Village Care Centre 27/11/08

Whiteley Village Care Centre 08/06/06

Whiteley Village Care Centre 04/10/05

Whiteley Village Care Centre 20/06/05

Whiteley Village Care Centre 06/01/05

Whiteley Village Care Centre 10/08/04

Whiteley Village Care Centre 24/02/04

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 Whiteley Village Care Centre Whiteley Village Care Centre Whiteley Village Walton On Thames Surrey KT12 4EH Lead Inspector Suzanne Magnier Unannounced Inspection 10th December 2007 08:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whiteley Village Care Centre DS0000017658.V352141.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. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whiteley Village Care Centre Address Whiteley Village Care Centre Whiteley Village Walton On Thames Surrey KT12 4EH 01932 825831 01932 825843 matron@whiteleyvillage.org.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) The Whiteley Homes Trust Mrs Nancy Hunter Care Home 114 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (114) of places Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 63 beds providing nursing care may be used to accommodated people from the age of 60 years 8th June 2006 Date of last inspection Brief Description of the Service: Whiteley Care Centre is located in Whiteley Village near Walton on Thames, Surrey. The Nursing Home offers accommodation for 63 residents and two residential homes, Ingram House and Whiteley House offer accommodation to 28 residents and 23 residents respectively. The village and care centre are set within the grounds of Whiteley Village in 230 acres of Surrey woodland. The Care Centre is owned and operated by the charitable homes Whiteley Homes Trust. The village is self-contained with its own village green, club, hall, churches, post office and store selling groceries and fancy goods. The accommodation provided at the care centre includes single or shared rooms some of which have en- suite facilities. Bathrooms and toilets are fully equipped and include disability aids and assisted bathing facilities. Spacious dining areas are available and a variety of sitting rooms in each of the establishments. The current charges at the Care Centre are as follows: Residential Care Whiteley House (standard size room) from £600.00 per week Ingram House (standard size en-suite) from £700.00 per week Nursing Care – from £750.00 per week Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Some additional standards were assessed and have been included within the report. Due to the compexity and size of the registered homes Ms S Magnier, Mrs Lesley Garrett and Mr Damian Griffiths Regulation Inspectors carried out the inspection and the registered manager/matron represented the service. For the purpose of the report the individuals using the service are referred to as residents/individuals people living in the home. The inspectors arrived at the service at 08.15 and were in the home for eight hours and fifteen minutes. It was a thorough look at how well the home is doing and included each inspector touring a specfied site which included the nursing and residendial homes. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspectors spent time talking with individuals living at the home in order to seek their views about the home and the care they receive. No responses to questionnaires that the Commission had sent out have been received prior to the writing of the report. The inspectors looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the homes Statement of Purpose and Service User Guide, residents care plans, daily records and risk assessments, medication procedures, staff files, a variety of training records, health and safety records, complaints procedures and several of the services policies and procedures. Following the previous key inspection in June 2006 the service has met all the requirements made. The home had submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection, some details of which have been added to the report. From the evidence seen by the inspectors and comments received, the inspectors consider that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 6 The inspectors would like to thank the residents, staff and the matron/manager for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? The homes management and staff have made improvements by reviewing care plans documentation and started to train staff in person centred care planning. There are improved systems for the managemnt of medication to ensure the safety and well being of residents. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 7 The activities provided by the home have been improved to offer and include more choice for residents. The home have secured an extra sixteen hours staff time for residents activities and have and have recruited more volunteers to support the activities programme. The manager explained that the home have recently changed the external catering service and the feedback from residents about their meals was favourable and has resulted in further consultation with residents about menu choices. The home has undertaken some refurbishment following the previous inspection, which included the installation of new boilers, upgrading of the sluice facilities, the installation of en suite facilities to two bedrooms, refurbishment of the ground floor and main reception area and have purchased an industrial carpet cleaner to ensure hygiene standards throughout the home. The homes complaints procedure has been reviewed and all staff have received safeguarding vulnerable adults training. The home have undertaken a staffing review and have introduced a twilight shift to ensure residents needs are met and have increased the staff ratio by three whole time equivalents in the nursing home with one member of staff on the early and late shift. The home have incorporated staff awareness of the need for equality and diversity issues to be addressed and catered for within the care home setting, through training, discussion and supervision. The home have implemented a quality assurance process in order to seek the views and opinions of the residents and also their relatives and friends. What they could do better: It has been recommended that residents are encouraged to sign their care plans in order to evidence that consultation has taken place and each individual agrees to the care being provided by the home. It is recommended that care plans be further improved to include a more person centred approach to reflect the individuality of the person receiving care and support in the home. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 8 It has been required that any hazards identified in a resident’s life must be risk assessed, fully documented and reviewed in order to ensure that the safety and wellbeing of the resident is maintained as far as reasonably practicable. All residents must have appropriate means for example call bells at their disposal in order that they can summon the assistance of staff. It is recommended that a more robust system for reviewing resident’s care plans is implemented for example that a review of the specific plan is documented as opposed to reviewing the care plan as a whole in order to confirm the current care provided to the resident and safeguard staff from any allegation of omission or neglect of care. 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. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 9 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 Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 10 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): 1, 3, 5, 6. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Prospective residents and their representatives have information about the home in order that they can make an informed choice about moving to the home. The homes admission and assessment procedures ensure that individual’s needs are appropriately identified and met. People are encouraged to visit the home prior to residency. EVIDENCE: The inspectors sampled the homes Statement of Purpose that had been updated in August 2007. The home has three individual service user guides, which detail services offered in the nursing home and the two residential homes. The matron/manager explained that the guides were being reviewed in order to include photographs and a differing format for example large print, audio tapes Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 11 for people with sensory impairments and different languages in order that the information is more user friendly and engaging for individuals to read or hear. Both the Statement of Purpose and the Service User Guide evidenced that appropriate information regarding the services of the home were clearly documented to inform prospective individuals or their representatives about the services provided by the home. The inspectors sampled 6 resident’s care plans and noted that each contained a documented pre admission assessment about the needs of the individual. Some forms sampled were named either initial or pre admission assessments and the manager explained that currently the home are changing the format of the assessments to include a more person centred approach to the care of individuals. It was confirmed that the information gathered by the matron manager who undertakes the pre admission assessments home forms the initial care plan for the individual. The Annual Quality Assurance Assessment (AQAA) received by the commission detailed that the home acknowledges that the quality of assessments by social services and health care professionals varies and sometimes not enough time is allowed for the home to undertake an effective assessment as residents are often discharged from hospitals or other establishemnts at short notice which makes it difficult for the home to gather all the necceccary information required for a thorough assessment. Prospective residents and their representatives are encouraged to visit the home and meet with other individuals and staff, stay for lunch or dinner to see if they would feel comfotable in the home enviroment. The home does not provide intermediate care. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 12 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, 10. Quality in this outcome area is adequate. This judgement has been made using a range of evidence including a visit to this service. The management of care plans need to be strengthened to include a more person centred approach. Risk management requires improvement to ensure the safety of residents in the home. Medication procedures ensure that medication is administered to residents in a safe and appropriate way. Disposal/procedures of medicines were appropriate. Resident’s dignity and respect is promoted. EVIDENCE: The inspectors sampled six residents individuals care plans which included plans from the nursing and residential homes. It was evident that the homes management and staff had made improvements regarding the planning and documentation of the care plans as required at the previous inspection. The care plans illustrated residents differing care needs and how care and support were provided by staff. All the care plans documented residents Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 13 individualised personal care needs, condition of individuals skin integrity and pressure areas, sleep patterns, sight, hearing and communication, oral health, nutrition, diet and body weight, mobility, medication, mental state, social interests, cultural needs, family involvement and daily records of care provided and activities undertaken throughout the day. It was noted that each residents care plan was stored in their bedroom and residents had access to their care plans and the inspectors confirmed with residents that they knew about their care plans. It was noted that no residents or their representatives had signed their care plans and the plans did not include a reference that the resident was unable to sign or did not wish to. It has been recommended that residents are encouraged to sign their care plans, where possible, in order to evidence that consultation has taken place and each individual agrees to the care being provided by the home. Care plans included a document known as an accountability sheet, which staff members complete following supporting a resident or having had some contact with a resident for example answering a call bell or providing a meal. The daily evaluation sheets were discussed with the matron/manager regarding some comments written by staff, which were viewed as being task focussed for example ‘bed made’ ‘checked he is fine’, ‘bed made every thing seems OK’. The matron/manager acknowledged that improvement needed to be made to the report writing to include a more person centred record rather than a task focussed record of the care provided to the resident. Staff spoken with during the inspection were confident in telling the inspectors how they support residents on a daily basis and it was evident that the staff were knowledgeable about residents needs and how they preferred to receive care and support from staff. Whilst sampling the care plans it was evidenced that the plans were not fully complete in detailing resident’s current care for example details of a residents mobility and support required with the use of aids did not match what the carer informed the inspector. The recording in care plans regarding wound care was not clear in detailing the current status and support being provided to the resident. There was insufficient information to demonstrate that several residents had had specialised input for example swallowing assessments, continence management and specific medication issues yet in discussion with the matron/manager some of the shortfalls were discussed and confirmed that residents had received consultation from specialist healthcare professionals yet this was not located in the residents files. Whilst sampling the care plans it was noted that each resident had two files one containing the care plans and one containing risk assessments and other documents. Management of the files could be strengthened as some file indexes were incorrect and did not relate to the contents of the folder. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 14 The care plans evidenced that the home undertakes risk assessments regarding the hazards identified in resident’s lives. Whilst sampling one residents care plan it was noted that a nutritional risk assessment did not include the residents weight and recorded that the resident could ‘eat independently, needs supervision’. Another care plan indicated that the resident had specific needs regarding fluid balance. The resident told the inspector that they were aware of their own hazards with regard to their health yet there was no indication that a risk assessment had been completed as this was not located in the residents file. Another nutritional risk assessment indicated that the resident has concern regarding weight loss and needs to be weighted every month. The records indicated that there were shortfalls and the residents weight had not been recorded on a monthly basis. It has been required that any hazards identified in a resident’s life must be risk assessed, fully documented and reviewed in order to ensure that the safety and wellbeing of the resident is maintained as far as reasonably practicable. Whilst sampling the care plans it was noted that reviews of the plans had taken place in 2007. It was evidenced that staff completed a list on the back of the care plan documents which detailed for example that sections 1-11 had been reviewed in November 2007 yet the care plan had been developed in April 2007. It is recommended that a more robust system for reviewing resident’s care plans is implemented for example that a review of the specific sections of the care plan is documented as opposed to reviewing the care plan as a whole in order to confirm the current care provided to the resident and safeguard staff from any allegation of omission or neglect of care. The inspectors and the matron/manager discussed ways in which the care plans could be further improved to reflect a more person centred approach, which could include more details about the individuals identity, personality and communication, past occupation, their lifestyle history and their hobbies and likes and dislikes as it was recognised that the care plans were essentially task based. The matron/manager acknowledged this that improvement and recommendation would benefit the individuals receiving care and support at the home and advised that this improvement was already currently being considered by the home and would be implemented in early 2008. The care plans included records of health care appointments that people had attended and also visits of health care professionals to the home. The health care professionals included the general practitioners, dieticians, chiropodists, physiotherapists and opticians, and specialised health care professionals. The inspectors were advised that a general practitioner (GP) from a local medical centre visits the home every day and the Thames Doc will visit the home at weekends. Residents spoke favourably regarding the arrangements for health care and stated that staff were also very kind and assisted the residents to seek medical support promptly. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 15 The AQAA received by the commission detailed that the home contacts specialist support groups and organisations to access the appropriate advise regarding the support needs for residents who may have specific needs for example support from the local Stroke Club. One inspector sampled the homes medication procedures and reported that the home has a medication policy and procedure. The inspector sampled one of the medication trolleys in the nursing home, which was stored in the locked clinical room. The inspector reported that the medication trolley was orderly, clean and was well stocked and that the home has a monitored dosage system (MDS), which is supplied by the local Pharmacist with procedures for ordering, returning and stock taking of medicines evidenced as robust. The inspector sampled the MAR charts, which were generally accurately completed by staff administering medication. The inspector observed a staff member administering medicines and noted that some staff had not documented when residents have refused or not taken their medication. It has been recommended that the reason for not administering medicines should be recorded in order to evidence a clear audit of medications administered and to safeguard the staff member from any allegation of omission or neglect of care. The staff member advised the inspector that the home have a flexible medication procedure, which offers residents choice and control in their lives regarding their medication. Staff demonstrated good knowledge regarding the medication they were administering and medication training records confirmed that the home support staff in safely administering medicines including the use of specialised medicines and equipment. The inspector sampled and undertook and audit of the controlled drugs in the home and it was evident that regular checks were carried out to ensure correct stocktaking and a clear audit trail. During the inspection it was noted that there was a calm atmosphere throughout the home. Staff addressed people in a professional and caring manner. Individuals were addressed by their first or full name and where appropriate names of endearment were used to support trusting relationships. Staff were observed to preserve and maintain peoples dignity and privacy by knocking on their room doors and waiting to enter, supporting people discreetly to the bathroom and being observant and attentive to people who were not fully able to maintain their own dignity. Quiet areas in the home were available to people to use. Whilst touring part of the premises one inspector observed that a number of rooms had signs on the resident’s door asking the visitor to see the nurse in charge prior to entering the room. Staff advised the inspector that this was Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 16 due to infection control measures adopted by the home and visitors are encouraged to use the hand scrub available in the resident’s room. The displaying of notices on residents bedroom doors was discussed with the matron/manager who agreed that the practice did not fully reflect the resident’s rights to dignity and respect. Following the inspection the Commission for Social Care Inspection (CSCI) were advised that the home had adopted a more discreet system and notices from residents bedroom doors had been removed. It was also noted that some resident room doors had net curtains attached to the glass pane. One inspector observed that the curtains were transparent and would not afford total privacy for the resident. This was brought to the matron/managers attention and the inspectors were assured that an alternative would be used to ensure residents rights to privacy and respect. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 17 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, 15. Quality in this outcome area is excellent. This judgement has been made using a range of evidence including a visit to this service. Residents are able to exercise choice in the daily lives, maintain bonds with family and friends, and take part in social, cultural, religious and recreational activities. The home provides a healthy and balanced diet in pleasant spacious dining areas. EVIDENCE: The inspectors spoke to a variety of resident’s during the day all of which spoke highly of the activities, staff and general running of the home. It was noted that people were moving freely around the home, several people were observed reading the daily papers and chatting with other people in the home including staff. The home are proactive in providing residents with a choice of stimulating activities and have joined a national organisation to access information guidance, and training courses to improve the quality of social activities available to residents. One inspector spent time talking with the activities organiser who explained that the home offers keep fit, fun and games Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 18 sessions, a bridge club, coffee mornings, PAT dog visits and ladies social afternoon club, quizzes, afternoon tea and cakes, visits from the local school, reminiscence, films, Whist, sherry mornings, music, a library trolley, daily newspapers and magazines, computer training, aromatherapy, crafts, themed suppers for example Burns night and St Georges Day, and bingo. The home has increased the number of volunteers who help to run the mobile shop and provide weekly musical entertainment. Residents are supported to maintain links with the village community by attending the Drop in Club, going out for shopping trips, outings and attending external clubs such as the local stroke club. Activity charts were available throughout the home and staff explained that residents are involved in the planning the activities and have a choice in participating in activities. A sensory stimulation room is currently being developed and the inspector was advised that the facility would be completed by end of the month. The grounds of the home were evidenced as well maintained with a small courtyard area all of which are accessible to residents if they choose to use the garden area. Bird feeders were sited in the garden area and several residents told the inspector how they like to watch the different birds coming to the feeders. The AQAA received by the commission detailed that the home welcomes and supports all denominations and staff advised the inspector that the home promotes peoples spiritual and religious beliefs by providing church services within the village community and also that the home would support individuals to other denominational places of worship. The inspectors noted that there were visitors in the home who appeared at ease with the staff and were able to visit their relatives and friends in privacy. The home promotes the use of advocates where appropriate and has links with local and national advocacy services. During the morning the inspectors observed residents having their breakfasts in their rooms and later observed the midday meal and noted that the dining areas in the home were spacious and well decorated following recent refurbishments. The tables were set with clean laundered cloths, napkins, cutlery, condiments including sauces and appropriate furnishings to assist residents to eat their meals comfortably. The inspectors observed that menus were available and meals were served by staff from a heated hostess trolley and staff referred to a list detailing what resident’s had ordered prior to the meal. It was noted that fresh fruit and juices were available to residents during their meal. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 19 The home has introduced two sittings at meal times to ensure residents receive their meals in a relaxed and dignified manner whilst being supported by staff. Residents spoken with told the inspectors that the food was good and that they were also able to have choice although some residents had forgotten what they had ordered when asked on the day of the inspection. The manager explained that the home have recently changed the external catering service and the feedback from residents was favourable and has resulted in further consultation with residents about menu choices. Meals are being freshly prepared and cooked in the home’s kitchen and changes have included a cooked light supper and a selection of sandwiches, salads, omelettes, jacket potatoes and fish. The staff advised that the catering manager organises special diet menus for example soft and pureed diets and catering meetings are held to listen to the residents views and suggestions regarding their choice of meals. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 20 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, 18. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Residents are able to express their concerns and have access to a complaints procedure. They are protected from abuse and have their rights protected. EVIDENCE: The home has a clear complaints procedure. No complainant has contacted the commission with information concerning a complaint made to the service since the last inspection. The AQAA details that no complaints have been received since the last key inspection. Whilst sampling the complaints log the inspector noted that the home undertakes a full investigation of any complaints received by the home and details a clear chronology of events for example dates of correspondence and outcomes regarding complaints received by the home. The inspectors met one visitor to the home whom was due to have a meeting with the matron/manager and other representatives on the day of the inspection regarding a concern raised with the home. The inspectors were advised of the outcome of the concern and written confirmation as to the outcome of the concern was sent to CSCI to confirm the favourable conclusion. The home has the local authorities multi agency procedures for safeguarding adults and a whistle blowing policy and procedure, which is available to staff in Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 21 order to safeguard people in their care. The matron/manager advised that the home follows these procedures. There have been two safeguarding referrals under these procedures since the last inspection, which have been concluded. Staff spoken with during the inspection demonstrated an understanding of the procedures for safeguarding adults. Staff training records detailed that staff receive awareness training regarding safeguarding vulnerable adults. Where some staff had not attended the training plans were in place for the staff to attend the in house training in order to safeguard people in their care. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 22 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, 20, 22, 24, 26. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The physical layout and indoor and outdoor communal of the home enable residents to live in a safe and well-maintained environment. Resident’s independence is promoted and maximised using specialist equipment. Resident’s bedrooms are personalised and suit their needs. All areas of the home are clean and hygienic. EVIDENCE: During the tour of premises the inspectors observed that the home was well maintained and decorated. The home offers a homely atmosphere, which is enhanced by the framed pictures, fresh flowers and the homely décor. Areas of the home were noted to be clean and hygienic throughout. The home has undertaken some refurbishment following the previous Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 23 inspection, which included the installation of new boilers, upgrading of the sluice facilities, the installation of en suite facilities to two bedrooms, refurbishment of the ground floor and main reception area and have purchased an industrial carpet cleaner to ensure hygiene standards throughout the home. The inspectors observed staff using equipment in the home for example portable hoists, walking frames and other mobility aids to assist residents to safely move around the home or from one area to another. The bathrooms and toilet areas were noted as being clean and hygenic. The home have installed overhead tracking in bathrooms to improve residents safety when being supported by staff. It was noted that the maintenance staff were retiling a bathroom and the AQAA advises that the home are installing a new specilised bath for residents and a shower/wet room if residents prefer. The inspectors did not vist the laundry area but the AQAA advises that there are plans to build a new laundry. The homes indoor and outdoor communal areas were well maintained and appropriate access was available to all residents in the home if they chose to visit the gardens. The staff told the inspectors that there are plans to build a sensory garden which the residents can enjoy. Residents spoken with in their bedrooms told the inspectors that they liked their bedrooms, which were comfortable. It was noted that people’s bedrooms were individualised and some contained their own items of furniture, personal possessions, leisure items including televisions, radios, and books. Some people told the inspector that they had telephones in their rooms, which they enjoyed having in order to keep in contact with friends and family. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 24 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, 30. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The homes staff are trained, skilled and sufficient in numbers to support the residents. The home has a robust system for the induction, training development and recruitment of staff to ensure residents needs are met appropriately and safely. EVIDENCE: The inspector was advised that the home is currently supporting 114 residents and have a total of 97 staff. The staffing numbers on the day of the inspection were considered to meet the current needs of the residents. The home have undertaken a staffing review and have introduced a twilight shift to ensure residents needs are met and have increased the staff ratio by three whole time equivalents in the nursing home with one member of staff on the early and late shift. The inspectors observed throughout the day that call bells to summon assistance were answered promptly by staff. The home have upgraded and installed a call bell system, which records response times. The response times are audited on a daily basis to ensure response times are being met. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 25 It was brought to the matron/managers attention that the inspectors had noted during the early morning that several residents did not have their call bells in reach. It has been required that residents must have appropriate means for example call bells at their disposal in order that they can summon the assistance of staff. The matron/manager advised the inspectors that she would look into this concern as a matter of priority. Comments received on the day of the inspection regarding the staff at the home were favourable with residents telling the inspectors that the staff were kind, caring, thoughtful, and always willing to help. The matron/manager explained that the home employs a multi-cultural workforce and equality and diversity issues are addressed both by residents and staff. The home have undertaken a review of the staffing in respect of gender specfic care and have as a result changed the ratio of male to female carers to ensure all residents are comfortable with the gender of the staff member caring for them. One inspector sampled four staff recruitment files. All files evidenced that the home undertakes safe vetting practices concerning the recruitment of staff for example complete application forms, appropriate references, CRB and PoVA first checks and face to face interviews prior to appointment in order to ensure the safety and protection of residents. The AQAA received by the commission indicates that the home takes into account the views of the residents regarding staff recruitment by listening to their views at resident meetings and supporting residents to meet with prospective staff at the home. The staff induction and mandatory training records were sampled and evidenced that the home is committed to the ongoing training and development of staff and works closely with a local care association in order to ensure that the homes staff are suitably trained and competent in their duties. The records indicated that all staff undertake refresher courses where needed and these were identified through the accuracy of the record keeping for example a personal training record form. The AQQA indicated that 50 of staff had achieved their National Vocational Qualification (NVQ) in care with 10 working towards gaining the award. All Registered Nurses are registered with the National Midwifery Council and are encouraged and supported to develop their practice within the annual trainng programme in order to ensure residents needs are met appropriately and safely. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 26 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, 38. Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. The management and administration of the home are robust and the home is run in the best interests of the residents. Resident’s safety, financial protection and welfare are promoted. EVIDENCE: The atmosphere in the home was calm and orderly. The pace of the home was designed to meet the needs of the individuals living at the home and there was no sense of hurry. It was evident through observation and talking with residents and staff that the matron/manager had good knowledge about managing the care home and had the skills and experience to ensure the safety and well being of all persons in the home. It was observed that the Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 27 matron/manager has an open door policy to encourage people to engage with the management of the home at all times. The matron/manager explained that resident’s views about the service were actively sought and quality assurance procedures were in place to seek their views and the views of any visitors to the home. The views of residents are reported by the matron/manager to the Trustees at the residents and welfare sub committee meetings to ensure their views are promoted and incorporated to inform future developments and improvements in the home. The inspectors sampled some questionnaires that had been distributed around the home to ensure standards and quality. The home arranges support for residents whose first language is not English to express their views by seeking advice from local and national support groups to access advice and translation services, for example the Chinese Support Network for Older People. The home whenever possible, allocates a staff member who shares the resident’s native tongue to provide care and support for the individual. The AQAA advises that an external audit is also conducted regarding the home and the auditor spends three days seeking the views of the residents and produces a report promoting the views and advises the home on ways to best incorporate and improve service delivery. The views of the residents are also promoted in the wider community by publication within the village magazine. The inspectors were advised that the homes bursar safeguards residents finances if they choose to use this facility. The expenditure and accounting process is only undertaken by trained staff and relevant documentaion regarding the safekeeping of residents was clearly recorded. Each residents room has a locakable facility which residents are encouraged to use to safeguard their valuables. In general the home works proactively in the prevention of infection and infection control measures. The inspectors observed that the home has provided staff with individual hand gels and trained staff how to use them and additionally provided alcohol hand gels at reception and in all residents rooms and are educating visitors how to use them to prevent infection in the home. During the feedback to the matron/manager the inspectors discussed several observations, which included staff carrying soiled linen in bags and not wearing protective aprons when dealing with waste in the sluice area. The matron/manager understood the concerns of the break of the ‘triangle’ with regard to prevention of infection and has informed the CSCI following the inspection of the measures taken which include the purchase of additional laundry bags and stands and Infection control refresher training which will be held in the near future to ensure the safety and protection of residents. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 28 One inspector observed staff practice in the sluice area and noted that cupboard containing the COSHH (spray cleaner) product had been left open. One staff member did not relock the cupboard door whilst another staff member observed that the chemical was not in the locked cupboard and promptly returned the chemical to the cupboard and padlocked the door. During the morning one inspector observed that in a small fridge in the dining room a packet of salmon slices had been opened and not labelled. This was brought to the managers attention and a requirement has been made that all foodstuffs must be stored in compliance with food hygiene standards in order to ensure the safety and well being of all persons in the home. One inspector sampled the homes health and safety records which were evidenced as well documented and accurate and included fire safety records, water temperature checks and electrical and gas safety certificates. The matron/manager has advised that the water maintenance test certificate regarding the prevention of Legionella has been faxed to the local CSCI office following the inspection. Following the previous inspection the home have undertaken a review of the fire risk assessment and have installed self closing fire door devices to improve the safety of all persons in the home in the event of fire. The homes policies and procedures promote the health, safety and welfare of residents people in the home. Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 29 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 3 X 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 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 3 X 3 X X 3 Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 30 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 OP7 Regulation 13. (4 c) Requirement Any hazards identified in a resident’s life must be risk assessed, fully documented and reviewed in order to ensure that the safety and wellbeing of the resident is maintained as far as reasonably practicable. All residents must have appropriate means for example call bells at their disposal in order that they can summon the assistance of staff. All foodstuffs must be stored in compliance with food hygiene standards in order to ensure the safety and well being of all persons in the home. Timescale for action 10/02/08 2 OP27 13. (4 c) (6) 14/12/07 3 OP38 13. (4)(a, b, c.) 14/12/07 Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 31 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 OP7 Good Practice Recommendations It has been recommended that residents are encouraged to sign their care plans in order to evidence that consultation has taken place and each individual agrees to the care being provided by the home. It is recommended that care plans be further improved to include a more person centred approach to reflect the individuality of the person receiving care and support in the home. It is recommended that a more robust system for reviewing resident’s care plans is implemented for example that a review of the specific plan is documented as opposed to reviewing the care plan as a whole in order to confirm the current care provided to the resident and safeguard staff from any allegation of omission or neglect of care. 2 OP7 3 OP7 Whiteley Village Care Centre DS0000017658.V352141.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection South East Regional Contact Team The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT 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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