Inspection on 21/02/06 for Serenita

This inspection was carried out on 21st February 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Serenita 25/11/08

Serenita 19/07/07

Serenita 04/07/06

Serenita 22/08/05

Serenita 05/08/04

Serenita 22/05/04

Serenita 16/04/04

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Clouds House

Closereach

Westcliffe House

Hilldales

Longreach

Chandos House

Cherry Orchards Camphill Community Ltd

Broadreach

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

CARE HOMES FOR OLDER PEOPLE Russell Haven 15 - 19 Clevedon Road Weston Super Mare North Somerset BS23 1DA Lead Inspector Juanita Glass Announced Inspection 21st February 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 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. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Russell Haven Address 15 - 19 Clevedon Road Weston Super Mare North Somerset BS23 1DA 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) 01934 620195 01934 622670 Mr Nunzio Notaro Miss Patricia Elizabeth Waddington Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (2) of places Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. May accommodate up to 38 service users aged 50 years and over requiring nursing care. May accommodate two named people with Physical disabilities. This condition lapses when these people leave the home. Manager must be a RN on parts 1 or 12 of the NMC register Staffing levels detailed in the letter to Nunzio Notaro dated 22nd November 2004 apply. The Registered Manager is subject to three monthly reviews of the management of Russell Haven for the next year. The Registered Manager to receive regular supervision and support from Notaro Care Homes` Operational Manager and Administrator. May accommodate two residents who have a past / present alcohol dependency. This condition applies only to two longstanding, specific residents and lapse when those individuals leave the home 22nd August 2005 Date of last inspection Brief Description of the Service: Russell Haven is registered with the CSCI to provide nursing care to 38 residents aged 50 years and over. The home is located within walking distance of the beach and local amenities and is conveniently placed for access by public transport. All areas are accessible for wheelchair users and access to the upper floor is provided by a lift. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place in the presence of the registered manager Mrs P Waddington. Comment cards were received from 12 residents and 8 relatives and residents, visitors and staff were spoken to on the day. All comments were favourable and positive, however one visitor did comment on how clothing could be ironed better, this was discussed with the manager who agreed to talk to the laundry staff. One residents stated that the staff worked really hard to look after them, and another said how nice and polite they were. The manager continues to monitor the activities provided in the home and an outside entertainer was observed during the afternoon, one resident commented that he did not, ‘go much on organised activities but was always given the chance to join in.’ What the service does well: What has improved since the last inspection? Since the last inspection all contracts include the room number agreed with the resident on admission. All residents in the home are now covered by the homes registration category following an application for variation agreed with the CSCI. All radiators now have appropriate protective covers. A clear record of meaningful activities is now maintained. Staff are receiving training to take part in a pilot scheme with the Hospice in providing Palliative Care in the home. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 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 Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 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): 1, 2, 3 and 5. 6 does not apply The home provides adequate information for relatives and residents to make an informed choice before taking up residence. All residents have signed contracts. All residents are assessed prior to being admitted and a chance to visit the home is offered. EVIDENCE: The statement of purpose has not been revised since the last inspection, however it contains all the required information. Service user guides were seen in residents rooms, one residents said that they knew what it meant but said they had not looked at it since entering the home. Resident records reviewed showed that the manager carries out a full pre admission assessment of all prospective residents, she also confirmed that she receives a detailed assessment by telephone for emergency admissions. During the inspection the manager also discussed the need to re assess residents before re admitting them from hospital. Prospective residents are offered the chance to visit the home however relatives usually take this up on their behalf. Residents records also contained signed contracts/ statements of Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 9 terms and conditions, these now include the room number agreed with the resident on admission. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 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 and 11 Residents personal, social care, and health needs are fully met, and set out in an individual plan care. The recording of medication does not meet current requirements. Residents are treated with respect, and their rights to privacy are upheld. The homes policies and procedure for the care of the dying are appropriate to meet the needs of residents and relatives. EVIDENCE: Care plans continue to be very clear and concise, they contain all the appropriate information for staff and staff demonstrated an awareness of the content of the care plans enabling them to meet the personal needs of the residents in their care. All care plans contained very clear assessments of need and risk assessments, which showed clear evidence of regular review. Two identified residents with alcohol problems have specific risk assessments and very clear instructions for staff. Resident’s records show that they were assisted to attend health care services such as the GP surgery, chiropodist, dentist, optician and outpatient appointments. The home requests district nurse input when necessary. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 11 The manager carried out an audit of falls in the home, this showed times when residents were more at risk so staffing arrangements were adjusted to provide extra cover during these times, this is good practice. The home has very clear policies and procedures for staff to follow regarding the ordering, storage and administration of medication. However it was noted on examination of medication records that staff are continuing to make entries without signing them. This was a requirement at the last two inspections and must be complied with, it appears to be a recurrent problem with new staff and the manager agreed to discuss the issue at supervision. A random audit trail of medication held within the home showed that no errors were evident. During the inspection staff were observed to have a friendly, polite and respectful rapport with the residents. Residents spoken to confirmed that the staff actively promoted their privacy and respect. Staff are currently receiving training in Palliative Care pathways, enabling them to take part in a pilot scheme with the Hospice providing care for residents requiring palliative care, this is good practice and progress will be assessed at the next inspection. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 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 and 15 The home provides a programme of meaningful activities. Service users are encouraged to maintain contact with family and friends. Residents are encouraged to exercise personal choice where possible. Residents receive a wholesome appealing and balanced diet. EVIDENCE: The home provides a programme of meaningful activities for all residents who exercise personal choice on which ones to attend. Activities are provided by outside sources and include reminiscence, singing and dancing, visiting entertainers and games. Residents go out for outings and staff take residents out for walks along the promenade, or into town. Since the last inspection a record of activities provided is maintained. The manager has monitored the types of activities that residents prefer and has involved relatives with the organisation of more choices. Residents spoken to said that they felt they had enough choice of activities one said he did not really like to go to organised events but was always offered the chance to attend. Residents and visitors spoken to said that there were no restrictions on visiting times, one residents said she enjoyed her family coming and they were always welcomed. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 13 The home has a six week menu which is reviewed seasonally. Though the menu does not offer a choice of lunch meal there was evidence from the residents spoken with to show that other choices are provided when requested including vegetarian meals. A choice is offered for the evening meal between something cooked or sandwiches. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 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 and 18 The home has a satisfactory complaints policy and procedure, and clear guidance for the protection of vulnerable adults; all staff spoken to demonstrated a clear awareness of adult protection issues. EVIDENCE: The home has a robust policy and procedure for the handling of complaints, a record is maintained which shows the agreed outcome. One visitor said they knew who to approach if they needed to raise a concern and they felt that they would be listened to and taken seriously. The homes policies and procedures for the protection of vulnerable adults are very clear and concise. They are stored in the office and available for staff at all times; a copy of the North Somerset policies and procedures were also available. Staff spoken to had received adult protection training and showed an awareness of the issues. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 15 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 and 26 Residents live in a safe, well maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: A tour of the premises was carried out, the home was clean tidy and generally in good decorative order. The home is well-equipped to meet the needs of the current resident group. Residents were observed during the day to be using all the communal areas; both the dining room and lounge are well lit and well decorated making them both pleasant places to spend time. The home shows evidence of regular maintenance and all areas were very clean and tidy. All staff showed an awareness of infection control guidelines. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 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 and 30 The numbers of staff on duty are sufficient to meet the needs of the current resident group. Staff are suitably trained and competent to meet the needs of the client group. Recruitment procedures meet the current standard required. Staff receive training appropriate to the care needs of the residents. EVIDENCE: The home has sufficient staff to meet the staffing notice set by the previous authority. The duty rotas showed there was an adequate skill mix of staff on each shift and that the use of agency staff was kept to a minimum. Staff records inspected, which included the most recent employees; all contained the required checks and references, including evidence of POVA first confirmations. Care staff are encouraged to obtain their NVQ In Care, whilst other care staff are oversees qualified nurses awaiting adaptation. The registered providers show a very clear commitment to training for staff at all levels, including professional development for qualified nursing staff. Recent staff training included supervisory development, infection control, emergency first aid and protection of vulnerable adults. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 17 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, 32, 33, 36 and 38 The manager is qualified, competent and experienced to run the home, the management ethos of the home is open and approachable. Residents’ opinions are sought about the way the home is run. All new staff are offered a full induction and all staff receive formal supervision. The implementation of health and safety within the home is satisfactory. EVIDENCE: The manager is a qualified nurse with 12 years experience in management she is currently doing the Registered Manager Award and is an NVQ assessor; both residents and staff spoken to stated that the manager was always ready to listen to them and spend time with them, an easy and friendly rapport was noted. The home carried out a quality assurance audit, which involved residents and relatives asking for their observations regarding the service provided, the audit was largely positive and suggestions considered, another is Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 18 planned for later this year. The manager has also held relative and resident meetings involving them in the running of the home. All new staff are given a full induction, this includes an induction for registered nurses which looks at the National Minimum Standards. Staff records showed that supervision agreements had been signed and records of supervision showed that areas of practice had been discussed and training needs identified. The implementation of health and safety was satisfactory. The fire log showed that the required checks and training was being carried out. The home has clear generic and working risk assessments, which showed evidence of regular review. COSHH data sheets were up to date and identified chemicals in use in the home, they were readily accessible and staff spoken to knew where to find them if they needed them. Staff demonstrated an awareness of infection control guidelines. Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 3 Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES 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. 1 Standard OP9 Regulation 13(2) Timescale for action Handwritten MAR sheets must be 21/02/06 signed by the person making the entry. Requirement 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 Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. Extracts may not be used or reproduced without the express permission of CSCI Russell Haven DS0000020380.V281152.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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