Inspection on 22/08/05 for Serenita

This inspection was carried out on 22nd August 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 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 21/02/06

Serenita 05/08/04

Serenita 22/05/04

Serenita 16/04/04

Similar services:

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 Unannounced 22 August, 2005 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 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 D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Russell Haven Address 15 - 19 Clevedon Road, Weston Super Mare,Somerset BS23 1DA Telephone number Fax number Email 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 with nursing 38 Category(ies) of Old age (38) registration, with number Physical disability (2) of places Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. May up to 38 service users aged 50 years and over requiring nursing care 2. May two named people with Physical disabilities. This condition lapses when these people leave the home 3. Manager must be a RN on parts 1 or 12 of the NMC register 4. Staffing levels detailed in the letter to Nunsio Notaro dated 22 November 2004 5. The Registered Manager is subject to three monthly reviews of the management of Russell Haven for the next year. 6. The Registered Manager to receive regular supervision and support from Notaro Home operational Manager and Administrator. Date of last inspection 23 March, 2005 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 D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in the presence of the registered manager Mrs P Waddington. The inspection was overall positive and it was evident that Mrs Waddington had worked hard to comply with the requirements made at the last inspection. Residents spoken to were happy with the care provided and the afternoon was observed to be taken up with an outside entertainer who appeared to be very popular. What the service does well: What has improved since the last inspection? What they could do better: The manager has looked into care reviews and alternative care for identified residents who do not fall into the homes category but they are still at the home; a variation needs to be forwarded to the Commission for Social Care Inspection to request an addition to their registration to cover this. It was noted that staff are still omitting to sign handwritten MAR sheets; this was a requirement at the last inspection and must be rectified. The radiator in room 43 does not have a protective cover and its position in the room does pose a risk to residents, this radiator must be covered. All residents in Russell haven have a contract however they do not stipulate the room number agreed with them o admission. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 6 The home provides a programme of meaningful activities however a clear record is not maintained to show that residents do attend. The manager would benefit from attending the Adult Protection Alerters training provided by North Somerset Social Service. 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 D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 4 and 5 standard 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, however they do not include room numbers. All residents are assessed prior to being admitted and a chance to visit the home is offered. EVIDENCE: The home has a very clear statement of purpose and service user guide, a copy of which is kept in the entrance hall. One resident spoken to when sat in the hall said he had read it before and it described the home. Resident records showed that the manager carries out a pre admission assessment prior to admission and receives a detailed assessment by telephone for emergency admissions. 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 terms and conditions however it was noted that they do not include the room number that was agreed on admission, this needs to be included in the contract. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 9 Mrs Waddington showed a very clear awareness of the level of needs within the home and has been reviewing the needs of two identified residents who do not come within the homes registration. They have both been assessed for placement elsewhere however appropriate placements are not available. The situation was discussed with the manager who stated that the residents GP felt the home met their needs. The home must therefore apply for a variation to include their category on the registration. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10 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 respect, and their rights to privacy are upheld. EVIDENCE: Care plans reviewed were very clear and concise, and contained appropriate guidance for staff. Following a requirement made at the last inspection all care plans were consistent in their approach to recording care needs identified. 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. 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 inspection and must Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 11 be complied with. 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. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 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 standard(s) 12, 14 and 15 The home provides programme of meaningful activities however documentation does not support this. 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 dogs and games. Residents go out for outings and staff take residents out for walks along the promenade, or into town. It was discussed with the manager that a record of activities needs to be maintained, to show that residents do take part. Residents spoken to confirmed that they were encouraged to make personal choices where possible, one lady jokingly said, if I couldnt have my own say I wouldnt be here. another lady stated that she feels free to remain in her own room or to join in activities in the lounge. 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. Residents spoken to whilst awaiting their lunch said the meals were always nice and if there was something they didnt Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 13 like they could always request an alternative. The dining room is bright and airy and residents can choose where they sit at mealtimes. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 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 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 recording of complaints has been improved since the requirement made at the last inspection. One complaint received by the manager was fully documented identifying action taken and outcome, which included a protocol, put in place and agreed with the GP and relative. 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, however it was recommended that the manager attend the adult protection Investigators training provided by North Somerset social services. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 23, 25 and 26 Residents live in a safe, well maintained environment, with the exception of one identified room. Residents have access to safe and comfortable indoor and outdoor communal facilities and their bedrooms suit their needs. 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. Some residents particularly like to sit in the entrance area and watch the comings and goings in the home. Residents spoken to said they liked the home and the layout of the communal areas, some residents said they prefer to remain in their rooms. Rooms inspected were comfortably furnished and most were recently decorated, residents had personalised their rooms to differing degrees with their own furniture and ornaments. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 16 The home was well lit, well ventilated and warm. During the inspection it was noted that the radiator in one room, currently unoccupied, did not have a protective cover, the position of the radiator posed a clear risk to any resident occupying that room. This radiator must have a protective covering. The home has an infection control policy and during the inspection staff were seen observing good hygiene practices. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 The numbers of staff on duty are sufficient to meet the needs of the current resident 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. 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 D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 37 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, one resident said that she was a very warm and understanding person. The home carried out a quality assurance audit, which involved residents and relatives asking for their Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 19 observations regarding the service provided, the audit was largely positive and suggestions considered, another is planned for later this year. 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. All records in the home with the exception of the medication sheets already discussed were well maintained and up to date. 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 D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 x 2 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 Standard No 16 17 18 Score 3 x 3 3 3 3 x x x 3 3 Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 21 YES Are there any outstanding requirements from the last inspection? 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 OP2 Regulation 5(1) Requirement Contracts/statements of terms and conditions must include the room number agreed on admission. The registered provider must apply for a variation of conditions, in relation to the two identified residents. Handwritten MAR sheets must be signed by the person making the entry. The radiator in room 43 must have a protective cover. Timescale for action By 23/09/05 By 23/09/05 From 23/08/05 By 23/09/05 2. OP4 12 3. 4. OP9 OP2.5 13(2) 23(1a) (2p) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP12.3 OP18 OP23.6 Good Practice Recommendations A record of activities and residents attending needs to be maintained. The manager needs to attend the Investigators training in POVA provided by N Somerset Social services. The use of room 43 as a double room needs to be revised. Russell Haven D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier 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 D53 - D02 S20380 Russell Haven V237287 220805 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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