Inspection on 21/09/05 for Safe Harbour Nursing Home

This inspection was carried out on 21st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Safe Harbour Nursing Home 02/07/07

Safe Harbour Nursing Home 18/02/06

Safe Harbour Nursing Home 02/11/04

Safe Harbour Nursing Home 05/05/04

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 Safe Harbour Nursing Home Abbots Drive Bebington Wirral CH63 3BW Lead Inspector Jeanette Fielding Unannounced Inspection 21st September 2005 10:20 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 Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 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. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Safe Harbour Nursing Home Address Abbots Drive Bebington Wirral CH63 3BW 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 643 1591 francesblackburn@onetel.com Dr Kumar Shyama Singh Frances Blackburne Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two (2) named female adults under 65 years of age One (1) named male adult under 65 years of age Date of last inspection 2nd November 2004 Brief Description of the Service: Safe Harbour is a modern, purpose built care home. It is located in a residential area close to shops and other local amenities. It is registered to accommodate 47 elderly persons who require nursing care. The home is on two floors with bedrooms, lounges and dining rooms on both floors. A passenger lift provides full access to all areas of the home. The home provides both single and shared rooms and some rooms are provided with en-suite facilities. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted over a period of six hours on one day. During the inspection discussion was held with the manager, care manager, staff and service users to obtain their views of the home and of the service provided. Records relating to the care of the service users were found to be extremely detailed and informative and provide staff with all the information necessary for the appropriate level of care to be provided. A recent incident at the home required that the procedures for staff recruitment and adult protection procedures were inspected. It is evident that all checks are made on staff prior to them commencing work at the home and that the home took the incident extremely seriously. Appropriate action was immediately taken to ensure that the service users were protected and to prevent re-occurrence. The home is extremely well maintained and is decorated and furnished to a high standard. Staff are well trained and given every opportunity to further develop their careers. What the service does well: What has improved since the last inspection? What they could do better: The home should continue to review and further improve the services offered to service users. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 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. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 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 Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 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 Comprehensive assessments are undertaken on all prospective service users to ensure that their individual care and social needs are identified and are met. EVIDENCE: Comprehensive assessments are made on all prospective service users prior to their admission to the home. These assessments are undertaken by the manager or care manager who are both registered nurses. Information is gathered from the service user, family members, GP, hospital staff and any other person who has been involved in their care provision. The assessment identifies specific care needs and provides the opportunity to identify any specialist equipment necessary and to ensure that the equipment can be put in place prior to the service users’ admission. The assessment form is completed and held on the service users’ file. The files inspected were found to contain considerable information regarding the service users and were used as a base for the preparation of the care plan. Individual preferences are recorded and care and social needs are identified. The records held were detailed and informative. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 The care plans at this home are detailed and informative to enable staff to provide the appropriate level of care required by each individual service user. EVIDENCE: The care files continue to be improved using the new format. This format ensures that all information is recorded within designated sections to provide ease of access to the staff. Comprehensive plans have now been prepared for all service users, although some are not yet in the new format. Risk assessments have been prepared and risk management strategies put in place to remove or reduce risks. Nutritional assessments have been undertaken together with falls risks and Waterlow assessments and appropriate plans set in place where these are required. Care plans are agreed with service users or their next of kin where possible and are signed to indicate the agreement. Agreements are also signed where it is identified that bed rails, or other protection for service users whilst in bed, are identified as necessary. All care files are reviewed each month and amended where the needs of the service users have changed. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 10 Records are held of all visits to and by GP’s and other healthcare professionals together with information regarding identified changes to care provision. Service users have access to all primary healthcare facilities in the community. The services of physiotherapists, occupational therapist, dieticians and speech and language therapists are sought whenever necessary. The home has a policy and a procedure to be followed for the receipt, recording, storage, administration and disposal of medicines. Registered nurses administer medications to all service users and all records inspected were found to be clear and up to date. The home has a policy and procedure to be followed in the event of a service user wishing to administer their own medications and this can only be agreed to following a full risk assessment. Personal care is given to service users in the privacy of their bedroom or bathroom as appropriate. The home has four double bedrooms and these are provided with screens to ensure that privacy and dignity are protected. Care staff were observed to be polite and courteous when assisting service users. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 11 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 Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: The routines within the home are flexible to meet the needs and preferences of the service users. A high number of activities are provided in both group and individually and staff respect the views of those service users who choose not to participate. The home employs an activities co-ordinator for 20 hours each week, and these hours are sufficiently flexible to provide both day and evening activities appropriate to the individual service users. Service users are given every opportunity to choose and develop their own lifestyle within the home. Individual preferences are recorded on care plans including the times that each service user likes to go to bed and rise. Service users spoken to confirmed that few restrictions were placed upon them. Plans are in place for the activities co-ordinator to undertake formal training and to obtain accreditation in the area of activities and social stimulation. Visitors are welcome to the home at any time and may meet with service users in the privacy of their bedroom or in one of the communal areas as they wish. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 12 The programme of activities includes: a visiting library, talking books service, weekly social evening, craft sessions, card and board games and bingo. Service users spoken to explained that the recent craft sessions had included making cards and key rings to sell at the summer fair. The money raised from the summer fair will be used for trips out and future social events. Ministers of religion visit the home on a regular basis. The Church of England minister provides services fortnightly, which includes hymn singing to the home’s organ. Service users spoken to said that they really enjoyed the singing. A local Priest and Nun visit the home and provide services and Ecumenical services are held each week. Service users said that they had enjoyed services provided by a visiting Priest from Zimbabwe who was a friend of one the service users relatives. One service user attends a day centre each week and some service users are taken out by family or staff. Service users are encouraged to bring personal items into the home such as pictures, photographs and other items of memorabilia. It is evident that staff strive to provide a homely environment for the service users. Meals are served in the two dining rooms and in the service users own bedroom as they wish. Breakfast served between 07:30 to 9:30 hours. Lunch is served between 12:30 and 13:30 hours, this is the main meal of the day. Tea is served between 17:00 to 18:30 hours. Supper is served between 20:00 and 21:00 hours. The menu cycle is run over a four weekly cycle but this may be changed according to season and service users preferences. There is always an alternative choice to the menu on offer and the cook will do an additional meal for those service users who wish to have something different. Service users may choose from a variety of meals. Meals seen were well presented and looked appetising. Special diets are catered for following the advice of the GP or dietician or on the request of the service users. The menu is displayed on the notice board on a daily basis to remind service users of the meals that they have chosen. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 13 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 Staff have a good knowledge and understanding of Adult Protection issues to protect service users. EVIDENCE: The home has a complaints policy and procedure which is detailed in the Statement of Purpose, the Service User Guide and is also displayed in the home. It is evident that staff have attempted to resolve all complaints made. The manager, care manager and staff have all undertaken training in the different types of abuse and of the action to be taken in the event of abuse being suspected. The records held in the home, following a recent allegation, provide evidence that all allegations are taken very seriously and that action is taken appropriately. The home has a whistle blowing procedure whereby staff and any other person can speak confidentially to the manager or care manager in the knowledge that action will be taken. The home has a copy of Wirral Borough Councils Adult Protection procedure and the manager and care manager were able to demonstrate that they were fully aware of the procedure to be followed. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 14 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 Recent investment has continued to improve the appearance of this home creating a comfortable and safe environment for those living there and visiting. EVIDENCE: The home was purpose built to provide care for older people and is situated in a residential area close to shops and other amenities. Accommodation and communal areas are provided on two floors which are fully accessible by a passenger lift. One area of the lounge is now used for activities and has been provided with a table, chairs and storage area for the activities equipment. Redecoration continues within the home and at the time of the inspection, one bedroom and the ground floor corridor were being redecorated. Other bedrooms had been redecorated since the last inspection and fitted with new carpets. New flooring has been fitted to the dining room on the first floor and provides a bright and clean environment. Improvements continue to be made to the bathrooms to provide safe and pleasant areas. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 15 The home was noted to be clean throughout and no unpleasant odours were noted. The home has a policy and procedure to prevent the spread of infection. Appropriate arrangements have been made for the disposal of general and clinical waste. The laundry has a washing machine with sluicing facilities with an Ozone machine to ensure that all germs are killed. Service users personal clothing was laundered to a high standard. Service users clothes are labelled and some items are laundered in mesh bags for protection. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 16 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 The staff have a good understanding of the service users’ support needs through on-going training to ensure that they can meet service users individual needs. EVIDENCE: The home employs qualified nurses at all times, supported by care staff to provide care, supervision and support to the service users. The staff rota provides evidence that sufficient staff are employed and deployed to meet the needs of the service users. Staff training continues to take place with a number of care staff currently working towards attaining NVQ at level 2. It is expected that the home will achieve 50 of care staff trained to this level by the end of the year. All vacant positions are advertised in the Job Centre and in the local press. Candidates are required to complete an application form prior to attending for interview. Two references are taken on all staff together with Criminal Record Bureau checks and the Protection of Vulnerable Adult register. The staff records inspected provide evidence that all checks have been made on staff and that contracts of employment have been issued. All new staff are required to complete a comprehensive, three month, induction training programme which includes fire lectures, fire drills, first aid, Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 17 basic food hygiene and manual handling. Specialist training is given to qualified nurses to update or provide them with new skills. Six of the nurses are currently undertaking training in Tissue Viability and training has recently been given on resuscitation and Phlebotomy. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 18 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 The manager has a good understanding of the areas in which the home needs to improve. Planning was in place and set out how this improvement was going to be resourced and managed. EVIDENCE: The manager, and the care manager, are both qualified nurses and are currently working towards attaining an NVQ in management at level 4. Evidence of on-going training was seen to demonstrate that they continue to update and improve their knowledge, skills and understanding. The manager stated that she has an open door policy and is available for staff and service users at all times. Staff spoken to confirmed that the manager is approachable and that the home has an open and positive atmosphere. Staff also commented on the great range of improvements that have taken place within the home since the current manager came into post. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 19 The manager undertakes audits on care plans, falls and care provision. Considerable improvements have been made to the care plan and the manner in which the care provision is recorded. The views of service users and their families are gathered from one to one discussions and at meetings held with family members. The home is currently working towards attaining Investors in People accreditation. The manager does not deal with any of the service users finances. Accounts can be made available for inspection on request. The home is insured and the certificate is displayed as required. Health and safety issues are addressed by the manager and maintenance staff although all staff have been given training in health and safety and are aware of their role and responsibilities relating to these. One of the maintenance personnel has recently undertaken a comprehensive three-day training on health and safety. Two other personnel are on day release training to further their careers. Checks on the fire detection equipment is undertaken as required and is duly recorded. Fire drills are held and training is given to all staff regularly to update and reinforce the procedures. Safety certificates were inspected and it was found that both the Gas and Electrical wiring certificates are due to be renewed within the next few weeks and arrangements are in place for these to be renewed. These will be inspected at the next inspection. All other certificates were in place and were valid for several months. Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 20 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 X 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X N/A X X 3 Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 21 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 Safe Harbour Nursing Home DS0000039379.V252861.R01.S.doc Version 5.0 Page 22 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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