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: 11th April 2024
- Visiting Officers: Caroline Roberts, Contracting Monitoring Officer (CMO)
- Present: Jayne Coburn, Registered Home Manager (RM) / Shah Seehootoorah, Responsible Individual (RI)
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 owned by Banyan Care.
The last full monitoring visit was conducted in March 2023.
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.
Previous outcomes
Corrective
For staff to receive timely supervision (no less than quarterly). RISCA, Reg. 36 Timescale: Immediately and ongoing – Met.
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 MET.
For a copy of an individual staff members birth certificate to be retained on their staff file. RISCA Reg 59 MET.
Developmental actions
For the home to consider writing personal plans in the first person - Ongoing.
For the staff to ensure that correct terminology is transferred from the Local Authority Care Plan to the homes Personal Plan. MET.
For the home to share any compliments or complaints with the Commissioning Team. Ongoing.
For the RI and Home Manager to consider amalgamating the daily records to one record. MET.
Findings
Responsible Individual
Mr Seehootoorah continues to be 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 should the RI and RM be absent at the same time, would be the support of Mrs Sheehootoorah and Mr R Sheehootoorah.
The RI is heavily involved in the home, and it continues to be evident that he has a good relationship with the residents residing at White Rose.
Registered Manager
During the monitoring process, Ms Colburn was asked several questions relating to the service. It was confirmed that the RM only has management responsibility for White Rose and 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 RM feels supported by the RI who undertakes regular visits to the home.
The Registered Manager was asked about the application of Deprivation of Liberty Safeguards (DOLs) and the visiting officer was informed that all such requests were up to date; however, there remains an ongoing backlog for assessments with the DOLs Team.
Referrals to the GP are made weekly in time for their weekly ward round. The RM also advised that SALT (Speech and Language Therapy) referral had been made and that the home has 1 outstanding Occupational Therapy referral.
Documentation
Care Vision continues to be used by Banyan Care. The system is user friendly and each individual residing at the home, has their own individual electronic file.
The system has photographs of all residents and stores Personal Plans, Risk Assessments, personal weights, food and fluid intake, medication, activities etc.
During the monitoring visit, two resident files were viewed; records were viewed which captured individual or family involvement in the process.
Previously, it was suggested that personal plans be written in the first person; therefore, providing a more personal approach to the process. This remains ongoing.
Information from the Local Authority’s Care Plans had been appropriately reflected 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. Should a review be overdue, the red flag is a prompt for the manager to ensure the review is undertaken in a timely manner.
All Seniors have allocated residents to ensure all reviews are undertaken and in a timely manner. Should a red flag alert the manager of an overdue review, they will know the responsible senior. The said documentation was observed to have been reviewed in a timely manner.
It was positive to note that the daily recordings on Care Vision were observed to be more detailed and recorded the individual’s mood, dietary/fluid intake, personal care, activities, skin integrity etc.
Referrals to appropriate outside agencies were observed i.e. Covid Team, GP, Audiology, Social Worker 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.
Activities in which the individual’s par-take in are recorded and the outcome from the activity is documented.
Neither file held an electronic life history; however, the RM advised these are held in paper format on a separate file.
Medication Administration Records were observed during the visit and no concerns were observed.
Due to individual choice, only one file held a Do Not Attempt Cardio-Pulmonary Resuscitation (DNACPR) instruction.
Activities
The home employs an activities co-ordinator who works from 08:30-15:00hrs per day.
During the visit, the individuals residing upstairs were observed to be engaging in playing a hoop game and laughter and smiles were observed, whilst downstairs, staff were playing a word search game with residents and singing. Later that morning, a balloon game was taken downstairs and again smiles and laughter were observed, with encouragement being given by other non-participating residents. One of the residents informed the visiting officer “it was a bit of fun”.
A clothes seller also visited the home later that day and there was a hype of activity observed, with residents showing interest on the garments on offer.
The RM showed the visiting officer to the newly decorated hair/nail salon. It was observed to be bright and professionally laid out with various nail colours on show. All professional hair dressing equipment is available, and it was evident the home has pride in the room and the pleasure it gives the residents.
The residents have a knit and natter group and recently presented the local premature baby unit with knitted hats for the newborn babies.
The gentlemen at the home enjoy rugby/football days, with a pint, gardening, days out and have the option to visit the salon and have a haircut and/or manicure.
An Activities Board is on display highlighting what activities will be undertaken that day.
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.
The outside sensory area continues to be enjoyed by the residents, when the weather permits. Residents are looking forward to growing their own vegetables and planting new flowers.
One individual enjoys playing music on their Alexa and described their favourite artist to listen to.
Music is played throughout the home via Amazon Echo.
The home is fortunate enough to have its own minibus for residents to enjoy day trips to shopping centres, seaside trips etc.
Staffing and Training
The home is staffed by 5 care staff on day shift, and 4 care staff at night.
The home does not use agency staff and have a stable staff team.
The home uses classroom-based training and use an electronic training provision called Redcryer.
After staff training, staff are required to complete a questionnaire and discussions are held during monthly meetings and face to face supervisions. New skills/knowledge obtained from training is observed during their work practice. Staff are given the opportunity to identify any training needs.
No staff member is working more than 48 hours per week.
The Active Offer is implemented as the home has Welsh speaking staff members.
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.
Both files were observed to be holding a job description, detailed application form, interview record, with no gaps identified. There was a signed contract of employment, a copy of the individual birth certificate and a photograph of the staff members.
Training certificates are retained electronically, and the monitoring officer was provided with the home’s training matrix, which evidenced the required mandatory training courses, along with non-mandatory courses that assist with providing care and support.
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.
Whilst viewing the Care Inspectorate Wales (CIW) most recent report, it was noted that the home requires supervision to be held in a timely manner (on a 3 monthly basis). Whilst discussing this area with the RI, the visiting officer was informed that the RM is working to improve this, and this was observed whilst viewing the supervision matrix.
Supervision is held face to face and on a one-to-one basis. Work continues to take place to ensure that timely supervision is taking place in line with the regulations (at least three monthly).
Quality Assurance
The monitoring officer viewed 4 copies of the RI’s Quality Monitoring Reports. Each report was 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.
Policy and Procedures in place are reviewed annually.
Staff meetings are held regularly, and the visiting officer viewed the last 5 set of minutes, The meetings cover a variety of topics i.e. training, pressure relief, medication, workload, risk assessments, annual leave etc. There is also a WhatsApp group for the seniors to receive any urgent up-dates.
Resident meetings are also held, and the visiting officer viewed the last 5 set of minutes for the meetings. Invites to the meetings are also extended to the relatives. The meetings allow the residents to have a voice and to share with the staff team their wishes and feelings in respect of the food/menu, clothes, their rooms, activities, day trips, what they want to grow in the garden etc.
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 are 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.
Home Maintenance
The home continues to be supported by two employees who oversee the day-to-day maintenance.
Banyan Care continues to implement changes to the home, based on the residents needs and requirements. Previously, a gym was put in place; however, due to the lack of usage, it is planned that the room will be changed into a lounge area for the residents and visitors.
The home is decorated to a high standard making it a home from home.
The residents continue to enjoy the garden area, planting vegetables and plants for their enjoyment.
The home also continues to encourage the involvement from the local community by holding special events for all to enjoy.
Mealtime Experience
At lunchtime, the residents were observed to be seated in the dining room. Tables are laid with tablecloths, cutlery, and drinks were provided.
The visiting officer observed good interaction from both the care staff and kitchen staff. There was laughter and general conversation.
The kitchen area presented as clean and tidy, having appropriate storage and refrigeration areas. The home was last inspected by the Environmental Services Team 10 November 2023 and retained its rating of 5.
Fire Safety/Health and Safety
Fire drills are recorded, with no concerns raised.
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. Those observed were viewed to be undertaken in a timely manner.
Personal Emergency Evacuation Plans were observed.
Residents Finances
The homes administrator has responsibility of signing any money that enters the residents accounts, along with the individual who is leaving the money.
During the visit, the visiting officer viewed the record sheet along with the receipts that are retained.
Staff, Resident and Family Feedback
A conversation was held with a new 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 provide a care centred approach and how this is instigated depends on the individual. Should they see someone upset, they would try to determine why and offer reassurance.
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 and the communication difficulties they face.
The monitoring officer was advised that the carer felt flexible in their role and that they could just sit and talk to the residents. The staff member described the home as “like family and likes the atmosphere”.
During the monitoring process, the monitoring officer spoke to several residents including one individual who reminisced about their time doing national service, their family, and pets. Another resident who was new to the home, described why they have taken up residency at the home. The individual advised that they “love it” at the home and described all as “friendly and I have a nice room, I’m happy”. The individual was then happy to see their adult children visit and introduced them to the residents in the lounge area.
The visiting officer spent time with a visiting family member, and they advised how difficult it was to make the decision of moving their parent into the home. However, they felt that they knew White Rose was the right choice for them.
The relative advised that the home “is always lovely, friendly and lovely”. The relative explained that their relative can become anxious but the home is “fabulous and supportive”.
The family feel involved and should they have any concerns or complaints, would feel confident to raise them with the manager or the R.I.
When asked if there is anything they would like to see changed, the relative advised “no”. The home provides their parent with a good quality of life and that staff have gone out of their way to make their parent feel at home.
Corrective and Developmental Actions
Corrective
None identified during the visit.
Developmental actions
For dates of review to be included on the policy/procedure documents for reviewing transparency.
For the home to share any positive feedback with the Local Authority.
Conclusion
During the visit, it was positive to observe the residents’ enjoying activities, with there being lots going on for the residents to enjoy.
There was plenty of laughter and smiles observed, which evidences that people are happy in their home and with the support they are receiving.
Interaction was observed to be positive with the visiting officer observing good interaction between the staff and the residents, with the staff also demonstrating to the visiting officer, good knowledge of the individuals residing at the home.
The RI continues to play an active role at the home, visiting often and is known to each resident. He continues to implement changes that will enhance the lives of the people residing at the home and works in partnership with professionals also involved in the care of individuals.
The Home Manager and the RI continue to have a positive working relationship; therefore, evidencing a strong management team.
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: 08 May 2024