White Rose Care Centre
White Rose Way, New Tredegar, Nr. Bargoed, NP24 6DF.
Tel: 01443 837183
Email: Jayne.whiterose@banyancarehomes.net
Contract Monitoring Report
Name/Address of Provider: White Rose Care Centre, White Rose Way, New Tredegar NP24 6DF
Date of Visit: 22 & 27 March 2023
Visiting Officers: Caroline Roberts, Contracting Monitoring Officer (CMO)
Present: Jayne Coburn, Registered Home Manager / Shah Seehootoorah, Responsible Individual
Background
White Rose is a purpose-built home in New Tredegar, which is registered to provide residential care for 32 people who are 55+ years of age in need of personal care services with or without dementia / mental health and in need of personal care services.
The home is managed by Banyan Care.
The last full monitoring visit was conducted in April 2022.
A Monitoring Officer employs a variety of monitoring systems to gather and interpret data as part of monitoring visits, including observations of practice at the home, examination of documentation and conversations with staff, service users and relatives where possible.
Dependent on the findings within the report, corrective and developmental actions will be given to the provider to complete. Corrective actions are those that must be completed (as governed by legislation); developmental actions are good practice recommendations.
Findings
Responsible Individual
The Responsible Individual (RI) is Mr Shah Seehootoorah, and as part of the role there is an expectation that quarterly reports are produced reporting on the service’s performance and quality.
Mr Seehootoorah is RI for both White Rose and another home in Blaenau Gwent.
The Home’s Statement of Purpose was shared with the Monitoring Officer and was reviewed in September 2023. There is an expectation that this is reviewed on an annual basis and updated on an ongoing basis where changes are required. For transparency, the report should be dated to evidence when last reviewed and the current review date.
The contingency plan, if the Responsible Individual and registered Home Manager were unavailable, would be that the service would be managed by Mr Radeem Seehootoorah.
The RI is heavily involved in the home, and it was evident that he has a good rapport with the residents residing at the home.
Registered Manager
During the monitoring process, the Registered Manager was asked several questions relating to the service. It was confirmed that no more than the one service is managed. The Registered Manager is registered with Social Care Wales and holds a relevant NVQ qualification in Health and Social Care.
The property has CCTV throughout the home but without audio. There is a CCTV policy in place and appropriate signage on display.
At the time of the visit, there were no issues with the general maintenance of the property.
Individuals residing at the home, may alter the temperature within their room as they are individually controlled.
Should significant events occur, either relating to the home itself or the individuals residing within the Home, the Registered Manager is required [within The Regulation and Inspection of Social Care (Wales) Act - RISCA] to forward Regulation 60 documents to Care Inspectorate Wales [CIW], copying in the Local Authority’s Commissioning Team. At the time of the visit, there were no outstanding notifications.
The Monitoring Officer was advised that the RI visits the home at least 1-2 days and per week and is very supportive and interacts with the residents.
The Registered Manager was asked about the application of Liberty Protection Safeguards (LPS) and the visiting officer was informed that all such requests were up to date.
Documentation
The home uses Care Vision, which is an electronic recording system. The system has photographs of all residents and stores Personal Plans, Risk Assessments, personal weights, Food and Fluid intake etc.
During the monitoring visit, two resident files were viewed; however, with regards to the reviews being undertaken, there was no evidence to indicate that the individuals or their representative had taken part, or what documentation was used to feed into the review. This was discussed with both the Home Manager and the RI and they will look at incorporating an area on the electronic system to record such evidence of resident/representative participation.
It was also suggested that personal plans be written in the first person; therefore, providing a more personal approach to the process.
Information from the Local Authority’s Care Plans had been appropriately transferred to the homes Personal Plans. Risk Assessments were observed for falls, bruising, dehydration, social isolation, pressure ulcers, bedrails, verbal aggression etc.
Care Vision uses a traffic light system for reviews, red indicating that a review is overdue. The documentation was observed to have been reviewed in a timely manner i.e. monthly and any changes were documented.
The daily recordings on Care Vision were observed to be basic; however, whilst viewing another screen, more information was located. It is recommended that such information is amalgamated for ease of inspection/monitoring etc. This was discussed with the RI.
Referrals to appropriate outside agencies were observed i.e. Chiropodist, District Nurses etc.
Agreements for relatives to be contacted during an emergency or to be informed about incidents are retained separately and are stored in a lockable cabinet within the manager’s office.
One individual had their life history recorded, whilst the second individual did not, and the reason shared with the visiting officer is that the individual had only just moved into the home and was being worked on.
Medication Administration Records were observed during the visit and no concerns were observed.
Both records held Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR).
Activities
The home employs an activities co-ordinator who works from 08:30-15:00hrs per day.
Ladies were observed to have had their nails painted by the Activities Co-ordinator and enjoyed showing them to the visiting officer.
An Activities Board is on display highlighting what activities will be undertaken that day i.e. Quiz, Table Toss Bean Bags, Bingo, Music Instruments, Jenga, Trips down Memory Lane etc.
A few ladies advised that in the evening, a group of them like to gather in the one lounge, watch a film together whilst sharing chocolates and having a Bailey’s.
Some residents were observed playing Connect 4 and others a jigsaw and holding a general conversation regarding having their hair done with the visiting hairdresser.
Another individual advised that they enjoy a shopping trip to M&S with the Home Manager.
For individuals cared for in bed, RITA (Reminiscence/Rehabilitation & Interactive Therapy Activities - which is an all-in-one touch screen piece of equipment, which offers digital reminiscence therapy), kinetic sand, games etc. are used to offer stimulation.
There is an inviting outside seating area for the residents to enjoy during the warmer weather with a summer house.
During the last visit, the RI advised that he had plans to make use of the extended garden area at the front of the property and have a vegetable patch for the residents to enjoy planting and growing their own vegetables and fruit. Since the last visit, work has been undertaken and the extended garden area has been cleared and turned into an additional space for the residents to enjoy.
Music is played throughout the home via Amazon Echo.
Staffing and Training
The home is staffed by 5 care staff on day shift, and 4 care staff at night.
The home does not usually use agency staff; however, at the beginning of the year due to staff retiring, the home was required to use agency staff. Whilst not viewed, the RI advised that appropriate documentation was shared with the home, and they also undertook an induction with a senior prior to commencing their shift.
The home uses classroom-based training and there are currently 2 staff members that are qualified to train others in moving & handling. The home previously used an electronic training provision called ELFY; however, they are now using Redcryer.
After staff training, staff are required to complete a questionnaire and discussions are held during monthly meetings and face to face supervisions. Staff are given the opportunity to identify any training needs.
No staff member is working more than 48 hours per week.
The home currently has one staff member that is a fluent Welsh speaker.
During the monitoring process, two staff files were viewed.
Both files observed were found to hold all appropriate documentation and information i.e. two written references, a detailed application form, interview records and signed contract of employment. Whilst viewing the application forms, no gaps were observed as appropriate details were provided by the candidate.
Neither file held a job description and only one file held a copy of the individuals birth certificate.
There were copies of driving licences; therefore, providing a photograph of the individuals, along with up-to-date DBS (Disclosing and Barring Service) checks.
Training certificates were not observed during this visit; however, the RI advised that they are retained electronically, and the monitoring officer was provided with the home’s training matrix, which evidenced the training courses all staff have attended.
During the visit, no evidence was observed in respect of the staff obtaining their Social Care Wales qualification; however, it was explained that both staff members held their workbooks as they are currently working toward the qualification.
Supervision is expected to be undertaken on a 3 monthly basis and whilst viewing the supervision matrix, it was observed that this time frame is not always being adhered to.
Mandatory training was observed to be undertaken in a timely manner and non-mandatory training sessions are attended in order to assist the individuals being supported at White Rose.
Quality Assurance
Two concerns were raised with the CMO prior to the monitoring visit taking place. The first concern was in respect of care plans not being up to date and the number of staff leaving. During the 2nd monitoring visit, the social worker who had raised this concern was reviewing matters and found the areas of concern had been resolved. With regards to the number of staff leaving, the home has had a stable staff team for several years ‘and unfortunately, for the home, a few staff had decided to retire.
The second area of concern related to an individual where it was felt the home could no longer meet the person’s needs and terminology used in the Personal Plan that was not used withing the LA’s care plan relating to cognitive abilities. The home and the social worker worked together in respect of this matter and a change of placement was sought.
The monitoring officer viewed 2 copies of the RI’s Quality Monitoring Reports (March 2022-May 2022 & Aug 2022-Nov 2022). Both reports were observed to be comprehensive, with the RI reviewing a wide range of areas, such as Infections, Pressure Ulcers, Wound/Injuries, Medication Management, Complaints, Safeguarding, LPS etc. Both reports outline the RI’s findings and records areas of good practice and areas that require improvement. The RI also undertakes observation of practice, activities and obtains feedback from staff, residents, and relatives/visitors. At the end of each report, the RI outlines the improvements and the individual(s) responsible for implementing/overseeing the changes.
The home has a complaints system in place and on receipt of a complaint, a named person will be responsible for the administration of the procedure and every written complaint will be acknowledged within 5 working days. A complaint will be investigated within 14 days of being made and responded to in writing within 28 days of being made.
A Whistle Blowing policy is also in place.
Staff meetings are held regularly with a variety of topics being discussed i.e. medication, Care Vision, Pain Check, communication, supervisions etc. Minutes of the meetings are placed on the staff notice board for those who missed the meeting. There is also a WhatsApp group for the seniors to receive any urgent up-dates.
Resident meetings are held, and relatives are also invited to join. Residents discuss activities, trips to the beach, trips to the local parks, the food menu etc. Minutes of the meetings are taken and filed.
There are two handover books retained at the home (one on each floor) and feedback is provided at the end of each shift by the senior carer on duty. There is a 10-minute handover meeting at the beginning of each shift and any concerns may also be recorded within the Care Vision notes.
The Home Manager was able to advise what advocacy service would be accessed for an individual should it be required.
When asked what action is taken should it be felt that an individual is taking too much medication, the Home Manager explained that regular audits of medication are undertaken and anyone that may be possibly taking more medication than required, would be referred to the GP for a review.
Home Maintenance
The home is supported by two employees who oversee the day-to-day maintenance.
Since Banyan Care have taken over the running of the home the RI has implemented changes and has had work undertaken internally and externally.
The home has a gym, with equipment available for those residents who wish to par-take in gentle exercise.
The downstairs area of the home has been redecorated to a high standard, making it inviting for the residents and their visitors.
The RI has commenced refurbishing upstairs, and this is being done in a timely manner as not to cause any disturbance to the residents.
There is a café area for the residents to enjoy, where the room is decorated to evidence being a café and is light and airy; therefore, making mealtimes more enjoyable.
The corridor walls have been decorated, with flowers being placed on the walls for the residents to touch and explore.
The RI explained the plans he has for the extended garden area. It was previously a piece of waste land, which has been cleared and turned into a sensory garden. Residents will be encouraged to plant vegetables and flowers etc. and spend quality time enjoying the new sensory experience.
Mealtime Experience
At lunchtime, the residents were observed to be seated in the dining room, where a large table was laid with a tablecloth, cutlery, and drinks. The monitoring officer took the opportunity to speak with all residents and all stated they enjoyed the meals. The mealtime was a positive experience to observe, with care staff and kitchen staff all interacting with the residents and offering appropriate support where necessary. The chef made herself visible to residents on both floors and happily engaged with the residents and accepted any feedback.
During both visits, the chef could be overheard regularly offering and encouraging residents to drink (hot and cold).
The kitchen area presented as clean and tidy, having appropriate storage and refrigeration areas. The home was last inspected by the Environmental Services Team November 2022 and retained its rating of 5.
Fire Safety/Health and Safety
A fire alarm maintenance service was last undertaken on 15 April 2022.
Other checks undertaken by the Homes own maintenance team include i.e. fire control panel, alarm sounders, fire extinguishers, fire door, keypad deactivation, fire escapes.
Personal Emergency Evacuation Plans were observed.
Staff, Resident and Family Feedback
A conversation was held with a member of staff, during which, a variety of questions were asked. The member of staff explained that should they observe an individual to be upset, they would talk to them and try to offer them comfort.
The carer was able to provide the monitoring officer with information in respect of one of the residents. It was evident that the carer knew a lot of information about the individual.
The monitoring officer was advised that the carer felt flexible in their role and that they could just sit and talk to the residents.
During the monitoring process, the monitoring officer spoke to a number of residents and one resident, along with their visiting relative sat with the visiting officer and answered some questions on the home and the support provided.
The resident advised that whilst they do not really go into the lounge/dining area on a regular basis and described themselves as being “a loner”, they enjoy listening to a variety of music in their room. The RI, the Home Manager and staff regularly pop into the room for conversation, and this was observed during the visit. The resident described the RI as “like having another son”
The resident advised that the food was “excellent and if you don’t eat it, then it’s your own fault”. The chef was described as “really good and she comes to see me”. Monthly meetings are held with regards to the menu and suggestions are welcomed.
The resident informed the visiting officer that she enjoys shopping trips out and that residents take it in turns to go out on such trips.
The resident advised that the care staff “are really good but I’m independent”. Both the visiting relative and the visiting officer discussed the resident’s safety and the need to summon assistance from care staff as and when required.
With regards to advocacy, the resident advised that they could advocate for themselves, or their family members would advocate on their behalf.
The visiting relative advised that they always promote the home and that it is an excellent care home. The resident stated that it is “home from home” and that they were “very happy” residing at White Rose.
The room, like others, were nicely decorated and contained personal items.
Corrective / Development Actions
Corrective Actions
For staff to receive timely supervision (no less than quarterly). RISCA, Reg. 36
Timescale: Immediately and ongoing
For reviews of Personal Plans to evidence involvement of the individual / representative, daily records etc. RISCA, Reg 15 Timescale: Immediately and ongoing
For a job description to be retained on individual staff files. RISCA, Reg 38
For a copy of an individual staff members birth certificate to be retained on their staff file. RISCA Reg 59
Developmental actions
For the home to consider writing personal plans in the first person.
For the staff to ensure that correct terminology is transferred from the Local Authority Care Plan to the homes Personal Plan.
For the home to share any compliments or complaints with the Commissioning Team.
For the RI and Home Manager to consider amalgamating the daily records to one record.
Conclusion
The atmosphere at the home was found to be warm and welcoming, with plenty of smiles, laughter and singing observed throughout the day. Positive feedback was received from the residents and the staff employed at the home.
Good interaction was observed with the residents, and staff demonstrating knowledge of the individuals residing at the home.
The RI continues to implement changes to the home and continues to involve all parties.
The Home Manager and the RI continue to have a positive working relationship; therefore, evidencing a strong management team. There are plans to continue to improve the service delivery, with the RI wanting to make White Rose home from home for the current residents and for future individuals wishing to reside at the home.
The monitoring officer would like to thank the RI, the Home Manager, the staff team and the residents for their hospitality during the visit.
- Author: Caroline Roberts
- Designation: Contract Monitoring Officer
- Date: April 2023