Inspection on 04/01/07 for Riversdale Nursing Home

This inspection was carried out on 4th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Riversdale Nursing Home 26/01/06

Riversdale Nursing Home 25/07/05

Riversdale Nursing Home 13/12/04

Riversdale Nursing Home 20/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Riversdale Nursing Home 16 Riversdale Road West Kirby Wirral CH48 4EZ Lead Inspector Jeanette Fielding Key Unannounced Inspection 10:30 4th January 2007 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 Riversdale Nursing Home DS0000020919.V301075.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. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Riversdale Nursing Home Address 16 Riversdale Road West Kirby Wirral CH48 4EZ 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) 0151 625 2480 0151 625 0913 Mrs Margaret Armstrong Mrs Kate Armstrong Shone Julie Anne Cotgrave Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users should not exceed 34 OP (N) Date of last inspection 10th September 2002 Brief Description of the Service: Riversdale Nursing Home is family owned by Mrs M Armstrong and Mrs K Armstrong-Shone. The Manager of the home is Julie Cotgrave, a first level nurse. The home is registered to provide nursing care for up to 30 elderly people. The home is a three storey house set in secluded mature gardens, close to the shops and amenities within West Kirby. Two lounges and a dining room are located on the ground floor and overlook the rear gardens. Both single and shared accommodation is available and some have the benefit of ensuite facilities. A hairdressing salon is also provided. A selection of bathrooms and toilets are provided on all floors and assisted bathing facilities are available. Well maintained and secluded gardens are provided with seating, fountain, gazebo and walkways. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in one day, over a period of five hours. During the inspection, the records relating to the care required by and afforded to service users were inspected. Staff records were inspected and were found to contain all relevant information together with records of training undertaken. A tour of the premises showed that the home is decorated and furnished to a high standard and is well maintained. A programme of redecoration and refurbishment continues to further improve the home. The Registered Person, the Manager, staff and service users were spoken to during the inspection. Service users spoke extremely highly of the home and the care afforded to them. What the service does well: What has improved since the last inspection? What they could do better: The home should continue to provide a high quality service. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 6 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. Riversdale Nursing Home DS0000020919.V301075.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 Riversdale Nursing Home DS0000020919.V301075.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Informative pre-admission assessments are undertaken on all prospective service users to ensure that the home can meet their individual care and social needs. EVIDENCE: A comprehensive pre-admission assessment is undertaken on all prospective service users either by the Manager or one of the qualified nurses. A five page assessment is completed to ensure that the home can meet the prospective service users individual care needs and to enable any necessary equipment to be provided prior to admission. The assessment involves gathering information from the service users, their family, GP, hospital staff and any other person involved in their care. The assessment also identifies any specific equipment necessary to meet the service users needs and enables the home to obtain the equipment prior to the service users admission where necessary. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 9 During the inspection, the pre-admission assessments on all recently admitted service users were inspected. These were found to be comprehensive and contained all the necessary information to enable a plan of care to be produced. Information is recorded about individual preferences in addition to the care needs to enable special diets or other requirements to be planned. The home does not offer intermediate care. Riversdale Nursing Home DS0000020919.V301075.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The records relating to the care afforded to service users are clear and provide evidence that each service user is given the level of care necessary in line with their assessed needs. EVIDENCE: The care files for five service users were inspected. The files contained detailed care plans which gave full information regarding the service users’ health care and social needs, together with information on how these needs are to be met. Risk assessments were in place together full information on how the risks will be reduced or eliminated. The care plans include information regarding the service users individual preferences and choices to enable staff to meet the service users specific requests. Information is also held on the files of visits made to and by GP’s and other health care professionals. Details of action to be taken following these visits are recorded and appropriate changes are made to care plans as appropriate. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 11 The home also keeps a record of communications with family members and other relevant persons. Daily reports completed by the care staff provide evidence of the actual care given by the staff. Medications were found to be ordered, stored, administered and recorded in accordance with the home’s policy and procedure. The storage area was seen to be clean and organised and no unnecessary or unwanted medications were held. Appropriate disposal arrangements were in place for unwanted medications. Risk assessments were seen to be in place for those service users who administer their own medications to ensure that they could do so safely. Policies and procedures are in place to ensure that privacy and dignity are maintained and training in this is given to all staff during the induction training programme. Evidence of this training was seen on the staff files. Personal care is given to service users either in their bedroom or in the bathroom as appropriate. Service users may use their own bedroom or in one of the communal areas as they wish. The office can be made available for private meetings. The use of a mobile telephone is available to enable service users to speak with friends and family in private. Mail is delivered unopened and service users are addressed by the name of their choice. Staff were observed to knock on doors and to wait for an answer prior to entering. Screens are provided in shared bedrooms to ensure that privacy and dignity are protected. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A high level of social activity is provided in the home. Visits to shops and theatres are enabled to provide stimulation and to enrich service users lives. EVIDENCE: A high programme of social activities and stimulation is provided for the service users. An activities co-ordinator is employed, although all staff are actively involved with providing activities. The home has recently held a Christmas fair and entertainers visit the home on a regular basis. A group of service users recently visited a local garden centre for a Christmas afternoon where entertainment was provided. A visit to the pantomime was planned for the week following the inspection. A clothes party was recently held to give service users the opportunity to choose and purchase their own clothes. Family members are encouraged to attend all social events. The home has recently obtained two budgerigars and service users were observed to try to teach the birds to speak. Service users are taken to local shops and pubs at a time of their choosing. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 13 Ministers visit the home on a regular basis and provide services for service users. Relatives are encouraged to visit and are welcomed at the home at any time, although it is preferred that visits made in the dark evening during the winter months are pre-arranged to ensure security. The home has a minibus to give service users greater opportunities to go on trips or to the local shops. A hairdresser visits the home each week to provide a full hairdressing service for all service users as they wish. The home does not deal with any of the service users finances and so family members or an advocate are advised to act on their behalf. Service users are encouraged to bring in personal items and bedrooms were seen to contain pictures, photographs and items of memorabilia. It was evident that the staff strive to provide a homely environment for the service users. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 14 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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good knowledge and understanding of Adult Protection issues to ensure the protection of service users. EVIDENCE: A complaints procedure is in place and information on how to make a complaint is detailed in the Statement of Purpose. This information is also displayed on the notice board in the entrance area. No complaints have been received by the home or CSCI since the last inspection. The home give all service users, relatives and visitors the opportunity to compliment the home as well as to complain and a high number of complimentary cards have been received and are displayed. Policies and procedures are in place to ensure the protection of the service users. All staff are required to sign to indicate that they have read, understand and will comply with these. All service users are listed on the electoral register to enable them to cast their vote at elections. The home is not affiliated to any political party. Training has been given to all staff on the different types of abuse and of the action to be taken in the event of it being suspected. Evidence of this training is held on the staff files. Qualified nurses have been given training on the Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 15 Nursing and Midwifery Councils’ Code of Professional Conduct. The owner, Manager and staff spoken to at the time of the inspection were able to demonstrate their knowledge of Adult Protection issues. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 16 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): 19, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: The programme of redecoration and improvement of the home continues. Since the last inspection, the corridors have been redecorated and fitted with new carpet. A number of reclining chairs have been provided to offer greater choice to service users. Four bedrooms have been redecorated and are all rooms are bright and fresh. Ten new mattresses have been provided in line with the homes plan for improvement. All areas of the home are decorated and furnished to a high standard. The lounge and dining room were decorated following the last inspection and provide an extremely pleasant area for service users. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 17 Service users are encouraged to personalise their bedrooms with pictures, photographs and items of memorabilia. Personal clothing is laundered with care and is attended to on a daily basis. The home was clean throughout and is maintained to a high standard. Infection control policies are in place and it was evident that staff follow all procedures. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 18 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, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are well trained to ensure a high level of care and support to the service users. EVIDENCE: The staff rota provides evidence that the home employs and deploys staff in sufficient numbers to meet the needs of the service users. A qualified nurse is on duty at all times, supported by care staff who have all been given training in the care of elderly people. Additional staff are employed during the busy morning period to enable service users to rise and bathe at a time of their choosing. All prospective staff are required to complete an application form prior to being called for interview. Two references are taken and checks are made through the Criminal Records Bureau and the Protection of Vulnerable Adults register to ensure the protection of service users. A health questionnaire also has to be completed. All new staff are required to undertake a comprehensive induction training programme which is signed for by both the Manager and the member of staff following an assessment of competence. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 19 In house training is given to all staff as well as attendance at external training courses. A high number of training opportunities are offered and a record is held of all courses attended. A training pack has been prepared for each member of staff employed at the home which includes copies of policies and procedures. Specific packs have been prepared for qualified nurses, care, domestic and catering staff. This is to ensure that all staff are fully appraised of their role and responsibility within the home to further protect the service users. All new staff are employed on a six month probationary period. New contracts have been issued to all staff. The disciplinary policy has recently been reviewed and updated. Back to work interviews are now held for all staff who have been absent to enable support to be given where necessary. Staff records inspected were found to contain all necessary information together with evidence that appropriate checks have been made on them. Supervision is given to all staff on a regular basis and annual appraisals take place. These meetings provide the opportunity for staff to speak with the Manager on a one to one basis to discuss career development and to identify with any training needs and opportunities. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Registered Person and the Manager have a clear development plan and vision for the home which they have effectively communicated to service users, staff and relatives. EVIDENCE: The Registered Person and Manager of the home hold NVQ in management at level 4. The Manager is a qualified nurse who also holds qualifications in the care of older people, palliative care and in training and assessing. She was able to provide evidence of ongoing training and development. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 21 The Manager has an open door policy and is available to service users, relatives and staff. The owner is in the home most days and is involved in the day-to-day running. Staff meetings are held monthly and minutes are taken. Group staff meetings are held and also specific staff meetings i.e. qualified staff, care staff, ancillary staff. Supervision is given to all staff every two months and annual appraisals are undertaken to provide staff with the opportunity to review their own professional and career development and to identify training needs. The Registered Person has implemented the ‘Blue Cross’ quality monitoring standard and audits are regularly undertaken. Recent audits have been made on care, catering, administration and housekeeping. The audits involve gathering the views of service users, staff, relatives and care professionals. The findings are summarised in the service user guide. The home holds the ‘Investors In People’ quality assurance standard. Policies and procedures are in place to protect the interests of each service user and these are reviewed and updated on a regular basis. The home does not deal with any of the service users finances. Secure facilities are provided to store valuables and accurate records are held of these. All staff have been given training on health and safety and are required to read the policies and procedures relating to these. Safety certificates inspected were seen to be in place and up to date. Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 22 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 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 X 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X N/A X X 3 Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 23 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. 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. Refer to Standard Good Practice Recommendations Riversdale Nursing Home DS0000020919.V301075.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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