Care Home: Whitebourne

Similar services:

• The Shelley
• Springfield House
• Sutton Lodge Nursing Home
• St Helier`s Residential Hotel
• St Joseph`s
• Ridgemount
• Wingham Court
• Old Hastings House

What the care home does well Residents to Whitebourne received the information they needed to make a decision about moving into the home and a care needs assessments ensuring that their health safety and welfare would be promoted. The health and welfare of residents benefited from commitments to keeping care plans including health care records up-to-date and ensuring that medication needs were appropriately administered. The home had a collection of compliments received since the last inspection from relatives; Thank you for all the care and understanding you gave him, Thank you for helping (name) to move into the home. This was highlighted further by the following comment found in the `Annual Quality AssuranceAssessment` that seemed to highlight the home`s overall philosophy; `what they (residents) can do for themselves and `not what they cannot do`. Residents were able to enjoy an excellent selection of activities and support that ensured regular contact with friends, family and the local community. Residents benefited from a food selection of their choice and the home ensured that a good dietary balance was achieved. The Annual Quality Assurance Assessments (AQAA) states; Special diets are catered for by the cook, who will make a special effort to either get different foods in or cook the food that they The care home was aware of safeguarding vulnerable adults procedures actively reporting and joint working with the local social care team to ensure that service users were safe and protected from abuse Residents enjoy a clean, comfortable, homely and practically equipped and furnished home that ensured personal care needs were met. Care staff receive a good level of it training, benefiting residents whose care needs were being met. The residents and staff benefited from the management style in place and friends and family contributed to the running of the home, ensuring that residents care needs and aspirations where catered for. Health and safety practice was implemented at all times ensuring that the home environment was protected and safety promoted. What has improved since the last inspection? The process of reviewing personnel files was in hand, and references and employment histories had been updated. However, the work was still ongoing. CARE HOMES FOR OLDER PEOPLE Whitebourne Burleigh Road Frimley Surrey GU16 7EP Lead Inspector Damian Griffiths Unannounced Inspection 28th February 2008 10:00 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 Whitebourne DS0000039537.V357943.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. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Whitebourne Address Burleigh Road Frimley Surrey GU16 7EP 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) 01276 20723 manager.whitebourne@careuk.com manager.burroughs@careuk.com Care UK Community Partnerships Ltd Rosaline Ann Stevenson Care Home 63 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (57), Old age, not falling within any other of places category (5), Sensory Impairment over 65 years of age (1) Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide a placement for 1 named service user with (DE) over the age of 55 years. 22nd July 2006 Date of last inspection Brief Description of the Service: Whitebourne is a purpose built home designed for people with a range of physical disability and other care needs including dementia care. It is located in a residential area in Frimley and within walking distance of shops and local facilities. The home is owned and managed by Care UK Limited and is registered to accommodate 63 people over the age of 65. The reception and managers office are off the main entrance area. Residents accommodation is arranged on the ground and first floors, with the second floor being for staff only. Residents live in one of five suites, two of which are on the ground floor, and the other three on the first floor. The suites are interlinked and have a number of lounges and communal areas. Each floor has a dining room and a small kitchen. There is a passenger lift. The homes other facilities include a kitchen and laundry room. The home has a pleasant grassed area enclosed by wooden fencing, and there is adequate parking to the front and rear. Costs per Week: £750.00 to £850.00. Please note this price may vary due to the level of care needs assessed. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes The inspection of Whitebourne care home took eight and a half hours beginning at 10.15 and ending at approximately 17:30. The inspector spent the entire day with care staff and service users and stayed for lunch. Mr. Damian Griffiths, Regulation Inspector completed the visit. The home’s Registered Manager Ros Stevenson assisted the inspector throughout the inspection and represented the establishment and Care UK. This key inspection report takes into account information from the Annual Quality Assurance Assessment (AQAA) and the homes Customer Satisfaction Survey for Relatives and Friends published October 2007 that were provided by the registered manager. Samples from a number of service user and staff personnel files. Observation of staff practice, equality and diversity issues and feedback from eight, CSCI survey’s completed by service users, relatives and care staff have been included in this report. The inspector would like to thank service users, their friends and relatives and staff at Whitebourne for their time, assistance and hospitality. Comments taken from CSCI surveys, distributed on the day of the inspection, comments received during the inspection and ‘Annual Quality Assurance Assessment’ are in italics. Some words have been changed in respect of confidentiality and are featured within (brackets). What the service does well: Residents to Whitebourne received the information they needed to make a decision about moving into the home and a care needs assessments ensuring that their health safety and welfare would be promoted. The health and welfare of residents benefited from commitments to keeping care plans including health care records up-to-date and ensuring that medication needs were appropriately administered. The home had a collection of compliments received since the last inspection from relatives; Thank you for all the care and understanding you gave him, Thank you for helping (name) to move into the home. This was highlighted further by the following comment found in the ‘Annual Quality Assurance Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 6 Assessment’ that seemed to highlight the homes overall philosophy; ‘what they (residents) can do for themselves and ‘not what they cannot do’. Residents were able to enjoy an excellent selection of activities and support that ensured regular contact with friends, family and the local community. Residents benefited from a food selection of their choice and the home ensured that a good dietary balance was achieved. The Annual Quality Assurance Assessments (AQAA) states; Special diets are catered for by the cook, who will make a special effort to either get different foods in or cook the food that they The care home was aware of safeguarding vulnerable adults procedures actively reporting and joint working with the local social care team to ensure that service users were safe and protected from abuse Residents enjoy a clean, comfortable, homely and practically equipped and furnished home that ensured personal care needs were met. Care staff receive a good level of it training, benefiting residents whose care needs were being met. The residents and staff benefited from the management style in place and friends and family contributed to the running of the home, ensuring that residents care needs and aspirations where catered for. Health and safety practice was implemented at all times ensuring that the home environment was protected and safety promoted. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 were inspected. Quality in this outcome area is good. Residents thinking of moving to Whitebourne received the information they needed to make a decision about moving into the home, and received a comprehensive care needs assessment. This is to ensure that the home was familiar with their individual needs and were able to provide the support that was required. Whitebourne does not offer Intermediate Care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information about the home, such as the last inspection record, the statement of purpose and the complaints procedure were well presented in the entrance lobby. Residents to the home received a welcome pack giving useful details about the home. Residents completing the CSCI survey all agreed that they had received enough information about the home. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 9 Six care plans belonging to new and existing residents to Whitebourne were inspected and were found to contain a fully comprehensive care needs assessment that included information relating to; work and play, communication, behaviour, healthcare needs including skin care, mobility and personal care needs. Three service users surveys completed by residents of Whitebourne each agreed that they had received a contract, enough information about the home before they moved in and that they received the care support they needed. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 were inspected. Quality in this outcome area is good. The health and welfare of residents benefited from the home’s commitment to keeping up-to-date social and health care records and ensuring that medication was appropriately administered. Staff responses to residents’ rights to privacy were consistent but some attention was needed to promote a sensitive and respectful practice throughout the day. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had developed and was using a new computerised system ensuring that all care plans could be written up daily were easy to read and up-to-date, as was observed. Paper copies were made available but did not always correspond with the computer records; the daily records completed by hand that were on file showed limited attention to overall detail, mainly listing the residents eating habits and recording personal daily events. An examination of Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 11 the computer records showed that records of the service users’ activities that were listed in the care plans were included. All residents had a key worker allocated to ensure their individual care needs were being implemented. Photographs of the residents were to be found in the care plan folders that were helpful to new care staff at the home and also personalised the resident’s ‘Lifestyle’ book that the resident and their family had been involved in creating. Care plans were designed around the care needs of the residents and were considered to be an ongoing assessment process. Care plans were regularly reviewed for example; health care, attention to mobility and falls, risk assessments and interests and hobbies were some of the areas of care need regularly assessed. Regular exercise programmes were listed amongst the residents’ activities, and were evidenced in care plans. Records relating to service users’ health care needs had been kept and CSCI had received regular regulation 37 notifications from the home that evidence Whitbournes’ ability to appropriately manage a range of health care concerns. There had been a number of incidents of aggression recorded and reported to CSCI throughout the year. Therefore it was imperative that appropriate risk assessments were completed. Risk assessments were in evidence in all care plan folders ensuring that residents received individual attention to reduce harm. All risk assessments were reviewed in tandem with care plans. The home was currently reviewing the risk assessment format to improve understanding and it was brought to the managers attention that some risk assessments were not clear or were not within the care plan folder. Since the last inspection there had been three reports from the home of maladministration of medication. A thorough inspection of the homes medication practice and procedure was undertaken. Staff were observed administering prescribed daily medication to residents. The medication administration records (MAR) were inspected to ensure that the residents prescribed dosage was correctly given. The home has a designated area for medication storage and only senior staff were allowed to administer residents’ medication. The medication area was air-conditioned and environmentally controlled at a constant 20°C. Medication prescribed in individual packets and blister packs were checked against the day’s distribution. The management of controlled drugs was seen to be in order and appropriate storage was in place and drugs had been properly recorded in a separate book. Medication no longer required was returned to the pharmacy. An inspection of the drug returns book completed by senior carers was in order and the Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 12 pharmacy collecting the drug returns had signed for collection. The pharmacist’s signature could not be discerned from that of the senior care staff completing the book. It was therefore recommended that the pharmacist signature should be better defined. All medication administration records and procedures inspected were correct. Residents were addressed by their chosen name, when entering bathroom/bedrooms care staff always knocked on the door first before opening. Residents were observed chatting with care staff amicably, however, one instance was observed during the dinner hour that was the exception to the rule; this was between a member of staff and a resident with dementia care needs. The care worker entered into a disagreement over a relatively simple matter with the resident. The dispute was unnecessary and upsetting to other residents, a senior member of staff eventually diffused the confrontation without fuss. Four CSCI surveys were completed by residents during the inspection. Residents confirmed that they all received the care and support they needed, that staff listened to them and where available when they needed them. Medical support was always available and meals were always liked. Please refer to the recommendations section of this report. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is good. Residents were able to enjoy a selection of activities and support that ensured regular contact with friends, family and the local community. Residents benefited from a food selection of their choice and the home had ensured a good dietary balance was achieved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home prided itself on the their ability to provide varied and culturally responsive selection of activities for all residents. Friends of Whitebourne supported residents by ensuring additional people were available, promoted a positive image of the home, supported the manager/activities co-ordinator and helped to guarantee quality activities that were more accessible. Trips out to local community such as the pantomime, local museums and eating-places were regularly available and ensured there were more enjoyable activities available for families and friends to join in. The Annual Quality Assurance Assessments (AQAA) completed by the home ensured that; Residents who’s first language was not English could seek the skills of, a multi cultured staff group where a lot of different languages are Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 14 spoken so we have matched up some staff as the service users key worker so that they can, if they choose to speak in their mother tongue language (AQAA). Spiritual guidance and access to regular and nondenominational religious services were also available. The home produced a newsletter was produced once/twice a year. The current newsletter featured photos of residents engaged in the homes new activities based care (ABC) project that recognises that some residents still enjoy the opportunity to help out around the house with a bit of hovering or light dusting and positively highlights ‘what they can do for themselves and ‘not what they cannot do’ (AQAA). Other activities of more traditional type such as a visit to the pantomime to see the Wizard of Oz, sing-along and demonstrations of bell-ringing, aromatherapy were regularly available. Cultural evenings to celebrate things such as Burns night and haggis tasting, celebrations for the Chinese New Year, Italian restaurants and no doubt English culture such as the trip to the local pub. Care UK conducting its own Quality Assurance survey found that the majority of residents enjoy the food and felt that relationship between residents and staff were generally positive. Menus were available outside each dining area there being a dining area for each section of the home. The Annual Quality Assurance Assessments (AQAA) states; Special diets are catered for by the cook, who will make a special effort to either get different foods in or cook the food that they like. There was a choice of food available and residents consulted were satisfied with the system in place. The evening chef was observed preparing a vegetable soup made from fresh vegetables that was later enjoyed by the residents and scones without sugar also ensured that residents with diabetes were catered for. The inspector was able to have lunch with residents and observe care staff in areas such as medication administration, choice and control quality of meals and environment. Unfortunately, some residents had to wait for over half an hour for their meal, care staff did not apologise or explain the reason for the delay and neither did a maintenance man who wandered through the centre of the dining room. During this period, the residents also had to witness the altercation as described in the previous section. The commission accepts that staff response may have been affected by the presence of the inspector. Four CSCI surveys were completed by residents during the inspection. Residents confirmed that; activities were arranged that they could always take part in and meals were always liked. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 15 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 inspected. Quality in this outcome area is good. The home ensured that complaints procedures and residents’ safety were promoted and safeguarding issues actively followed up. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details on how to access the complaints system were available in the entrance foyer and featured in the service user guide. There were no complaints on record but a number of compliments were in evidence. The home had received a collection of compliments since the last inspection from relatives; Thank you for all the care and understanding you gave him, and, he enjoyed being in the home Care UKs Customer Satisfaction Survey covering areas such as; relationships between staff and residents, residents’ choices, respect, involvement and being listened to all scored highly. Residents meetings, trips out and opportunities to talk to the Friends of Whitebourne and people from outside the home enables residents to have the opportunity to make queries about the complaints system at the home. It is imperative however that residents disabled by memory and dementia care are attended to by experience staff at all times. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 16 The care home was aware of safeguarding vulnerable adults procedures actively reporting and joint working with the local social care team to ensure that service users were safe and protected from abuse. There had been several instances required safeguarding investigations since the last inspection that had been successfully concluded and the home had ensured that additional equipment/staffing were provided as appropriate. At the time of the inspection there was one outstanding safeguarding investigation to be concluded. Four CSCI surveys were completed by residents and care staff during the inspection. Residents confirmed that they all knew who to talk to if they were not happy and know how to make a complaint. Care staff confirmed that they knew what to do if a service users/relative friend or advocate had concerns about the home. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 17 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 inspected. Quality in this outcome area is excellent. Residents enjoyed a clean, comfortable, homely and practically equipped and furnished home environment inside and outside, that ensured personal care needs were met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises revealed a care home that was well cared for and much loved by the management staff, friends and family. Although decoration was in need of restoration in some areas due to general wear and tear an overall homely feeling was actively promoted by all. Fresh flowers could be found throughout the home, as were useful activities information, menus and directions. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 18 Residents enjoyed personalised rooms with appropriate name plaques and access to their own key is appropriate. Gardens were accessible and new garden furniture had been purchased, the ‘Friends of Whitebourne’ had contributed three rose bushes. Plans to increase and extend the homes leisure capacity by way of a new conservatory was being planned but this was dependent on monies being raised through charitable endeavours. The home is constantly being refurbished and ongoing painting and maintenance is implemented. Maintenance programme is in place (AQAA). Bath equipment, toilets and sluice areas were all clean and free from malodour and shower rooms had been refurbished. Four CSCI surveys were completed by residents during the inspection. Residents confirmed that they all thought the home was fresh and clean. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 19 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 inspected. Quality in this outcome area is good. Residents were well served by good staff recruitment and skill-mix and the staff were well supported by the management team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels at the home were observed to be working well apart from the lunchtime arrangements as observed. Although four staff members were available, two were new, one was attending to medication, and one was either behind the counter serving or away from the dining area chasing up the orders. It is recommended that the home review staffing levels and coordination during lunchtimes. Five care personnel files were inspected for evidence of appropriate skill mix of the staff on duty, new staff employed at the home and recruitment procedures. The Annual Quality Assurance Assessment (AQAA) confirmed that over 50 of care staff had achieved level 2 of the National Vocational Qualification (NVQ). Staff were actively supported to attain continuous professional development and costs were met by the home encouraging staff to attend a local college where relevant training was available. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 20 Recruitment procedures in place ensured that care staff files contain the necessary documentation; such as, photo ID, Criminal Record Bureau (CRB) disclosures, references, job applications and signed terms and conditions. It was noted that there were still some files that did not contain a full employment history. The home was aware of this and was conducting ongoing review of all care staff files. New staff to the home receive an induction programme and basic training relevant to the care needs of residents. The staff on duty had accumulated appropriate work experience and files inspected showed evidence of training relating to and including; food safety, safe manual handling, medication administration, first aid, safeguarding vulnerable adults and dementia care. Staff at the home also had access to a new computerised ‘self-learning’ programme in areas of health and safety such as; COSHH and safe manual handling. Four care staff surveys were completed during the inspection and all care staff confirmed that: recruitment was done fairly, one commented; Very pleasant polite on my interview. Comments relating to training included: We are given induction training before we start working: they also provide us with courses and training to update our knowledge in care, and another said: training always available if required. All care staff confirmed they were given training that was relative to their role and met the needs of the service uses relating to their disability, gender, age, race, ethnicity, faith and sexual orientation. Please refer to the recommendations section of this report. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 21 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 inspected. Quality in this outcome area is excellent. The management and staff team were working well together and had obtained skills and qualifications to ensure a safe, well run, and homely environment was maintained for the residents. Health and safety practice was implemented at all times ensuring that the home environment was protected and safety was promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) completed by the home confirms that the Manager has attained RNMH, NVQ 3, NVQ4, RMA and also Train-to-be-a-Trainer and other relevant courses. The manager operated an ‘open-door’ policy. Four care staff surveys were completed during the inspection and all care staff confirmed that information sharing with the Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 22 management team worked well and There is always someone senior available to ask anything. All agreed that the manager gave them enough support and met them regularly to discuss how they were working. The altercation, that was observed during lunchtime was discussed with the manager and highlighted the ease of which conflict could emerge when working with residents with complex care needs. Recommendations highlighting areas of improvement have been made. The inspector was able to see evidence that the home supported residents and their families to help complete ‘Lifestyle’ books. Regular service users meetings, consultations with relatives asking their opinions, surveys and a suggestion box in reception area encouraged relatives, health and social care practitioners and residents to comment their ‘Whitebourne’ experience. A newsletter was also sent out two to three times a year. The last ‘Customer Satisfaction survey for realtives and friends’ was published in October 2007 and was available to all those who participated. The home was committed to ensuring that resident’s finances were protected and residents could enlist the support of independent advocates. There had been no concerns recorded prior or during the inspection. There were no ‘Health and Safety’ concerns highlighted during the tour of the premises. The kitchen area although continuously busy was clean, hygienic and well ordered. Accessible training either by computer self-learning or the local college was available to all staff. Fire drills and equipment were regularly updated. The Annual Quality Assurance Assessment (AQAA) noted that; The home is constantly being refurbished and ongoing painting and maintenance is implemented. Maintenance programme is in place, fire log, fire risk assessment, staff training files, fire test and drills, emergency lighting checks, legionella checks, hot water checks, equipment checks, PAT testing, contract maintenance, laundry procedures and infection control procedures and also home policies and staff training. Please refer to the recommendations section of this report. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 23 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 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X X Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard OP9 OP27 Good Practice Recommendations It was recommended that the pharmacist signature should be better defined. It is recommended that the home review staffing levels and coordination during lunchtimes. Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone 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. Extracts may not be used or reproduced without the express permission of CSCI Whitebourne DS0000039537.V357943.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!