CARE HOMES FOR OLDER PEOPLE
Whitgift Foundation The Whitgift House 76 Brighton Road South Croydon Surrey CR2 6AB Lead Inspector
Barry Khabbazi Unannounced Inspection 10th January 2006 9:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 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. Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Whitgift Foundation The Address Whitgift House 76 Brighton Road South Croydon Surrey CR2 6AB 020 8760 0472 020 8681 1269 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 Whitgift Foundation Mrs Philomena Kavanagh Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd May 2005 Brief Description of the Service: Whitgift house is a care home that is also registered to provide nursing care. This home is owned and managed by the Whitgift Foundation which is a long established charitable trust. The philosophy of the Trusts founder was that both younger and older people should mix and be together. To this end the home shares its grounds with a secondary school and sheltered accommodation, which are both run by the same organisation. Many of the residents who come to live at the home have lived in the Trusts own sheltered accommodation. The grounds are large and well kept, and also contain many ancient trees, lawns and a cricket pitch. The residents have commented positively about the grounds and general environment. Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This home currently meets 37 out of 38 of the National Minimum Standards, a number of standards are exceeded, and the home has demonstrated many areas of good practice. There are no care related concerns with this home. All of the Commission’s service user and relative surveys have also confirmed this view, with only positive comments about the home being received to date. The key Standards identified throughout this report were all inspected at the last inspection. Please see that announced inspection report for a full audit of all the key Standards. This un-announced inspection focused on observing the morning routine for the service users and following up on previous requirements and identifying new issues arising. What the service does well:
The residents’ needs regarding terminal care and following death are met well and this Standard is exceeded for the following reasons: Additionally funded staff hours are provided to offer a continual vigil and someone to be with the resident at the end, if relatives are not available. Accommodation has been provided for family at these times. Funerals and memorial services have occurred at the home. The home has a chapel that provides private spiritual space for grieving and contact is maintained with relatives following the bereavement. Bedroom sizes and communal area sizes exceeded the National Minimum Standard, providing extra space for the residents. This year staffing has been increased beyond previous staffing quotas, with one additional staff member on duty in the morning and one additional staff member on duty in the evening. Additional specific activities staff are employed which creates a more consistent level and quality of activities. The home is situated within large and well kept grounds, which also contain many ancient trees, lawns and a cricket pitch. The residents have commented positively about the grounds and general environment. There are kitchenettes in some rooms and communal pantries, which promote independence, and are also additional facilities for visitors. Some bedrooms have letterboxes and doorbells, which are used and therefore promote privacy. The organisation provided a three-week handover between managers to promote good practice.
Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were all met at the last inspection and not re-assessed on this occasion. Please see the last report for details of all key standards. EVIDENCE: Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were all met at the last inspection and not re-assessed on this occasion. Please see the last report for details of all key standards. EVIDENCE: Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were all met at the last inspection and not re-assessed on this occasion. Please see the last report for details of all key standards. EVIDENCE: Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were all met at the last inspection and not re-assessed on this occasion. Please see the last report for details of all key standards. EVIDENCE: Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were all met at the last inspection and not re-assessed on this occasion. Please see the last report for details of all key standards. EVIDENCE: Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30. Although the residents are generally protected by the home’s recruitment procedures, retaining copies of documents used for vetting staff still needs to be improved. {e.g. proof of identification, copies of passports etc.} This is need to ensure that the residents are not put at risk. Staff are well trained and competent in there jobs. EVIDENCE: The last report recorded that, ‘In addition to the registered manager’s 40 hours there is a total of 594 care staff hours per week and 182.25 nursing hours per week. This is inclusive of 3 waking care staff at night. There are separate additional 3 domestic posts, a separate maintenance posts and a separate activities co-ordinator. The kitchen staff are contracted from a separate organisation. Agency staff are rarely used.’ This year the home’s staffing has been increased beyond previous staffing quotas, with one additional staff member on duty in the morning and one additional staff member on duty in the evening. This was not related to any staffing concerns raised by the commission. Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 14 At the last inspection it was ascertained that most staff member’s files contained: enhanced Criminal Record Bureau checks for both new and existing staff, the staff members full name and address, date of starting, qualifications, application form, copies of the qualification certificates, job descriptions, copies of identification checks in the form of a passport and a driving licence, or other documentation, two written references, and staff photographs. However, the four files sampled at the last announced inspection all contained some omissions, for example references or proof of identification were missing from both new and existing staff. The following requirement was then set to address this shortfall. All Elements of Schedule 2 {staff files} must be acquired before employment starts, in particular, two references and proof of identification. At this inspection the staff files were in much better condition containing most of the documentation required. The previous requirement is therefore met. {see below}. Although there was evidence of the home obtaining all the required documentation, copies of proof of identification were not taken in all cases. The following more specific requirement is now therefore set: Copies of proof of staff identification must be taken and held on files in all cases. In addition, one member of staff had been employed without an up to date Criminal Records Bureau check. This staff member did however not have unsupervised access to the residents. Although new staff may start work without an up to date Criminal Records Bearo check while one is being sought, if they do not have any unsupervised access to the residents, this needs to be agreed with the commission to ensure that there is no unsupervised access to the residents and that the required procedures are followed. The following requirement is set to address this: Where the home wishes to start a member of staff without an up to date Criminal Records Bureau check and no unsupervised access to the residents, the Commission’s procedures must be followed, which includes obtaining prior agreement from the Commission. The last inspection report also contained a requirement for all staff recruited since April 2002 to undertake a six week induction and six-month foundation training to National Training Organisation’s specifications and targets. The manager has now obtained the relevant training guidelines and induction training has started. This still needs to conclude and foundation training to begin within the NTO timescales. This requirement will therefore also remain in force until fully met. Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 15 Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 Health and safety policies and procedures do protect the residents. EVIDENCE: The last report recorded that all of the health and safety policies and procedures relevant to this standard were present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets have been observed and these substances were all locked away. All of the procedures and testing of systems required in Standard 38 were also inspected. Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 17 The last report also recorded that Fire exits on the first floor were not labelled as such. The following new requirement was set to address this shortfall. Fire exits must be clearly labelled. This had occoured by the time of this inspection and this requirement is therefore now met. Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 4 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 3 18 3 3 4 3 3 4 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP29 OP29 Regulation 29[1] 29[1] Requirement Copies of proof of staff identification must be taken and held on files in all cases. Where the home wishes to start a member of staff without an up to date Criminal Records Bureau check and no unsupervised access to the residents, the Commission’s procedures must be followed, which includes obtaining prior agreement from the Commission. Timescale for action 01/04/06 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Whitgift Foundation The DS0000019047.V276196.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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