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Inspection on 12/03/07 for Sabourn Court Nursing Home

Also see our care home review for Sabourn Court Nursing Home for more information

This inspection was carried out on 12th March 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is conveniently positioned for access to a range of local amenities. The home overlooks large well maintained gardens which are accessible to the residents. Many of the bedrooms overlook the gardens as well as the comfortable communal areas.The staff are smart and professional and welcoming to visitors. They demonstrate patience and respect towards the residents. The manager has good communication skills and works with her staff in running the home in the best interests of the residents. There are established audit systems at the home which help the manager to make sure that services and facilities at the home are monitored and maintained at a good level. There is a commitment to making sure that staff are properly trained and can effectively care for the residents. This includes National Vocational Qualifications (NVQ) for care staff.

What has improved since the last inspection?

The activities provision has improved with the appointment of a new activities organiser. There is an organised programme, which is circulated to residents on a three monthly basis. The home continues to operate at a good level providing a good quality of care for the residents.

What the care home could do better:

The manager needs to monitor the care records and work with her staff in making sure that the care records are relevant and up to date with enough specific detail to make sure that care needs are fully met. Recommendations appear at the end of the report.

CARE HOMES FOR OLDER PEOPLE Sabourn Court Nursing Home Oakwood Grove Leeds Yorkshire LS8 2PA Lead Inspector Catherine Paling Key Unannounced Inspection 09:40 12th March 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 Sabourn Court Nursing Home DS0000001369.V327087.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. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sabourn Court Nursing Home Address Oakwood Grove Leeds Yorkshire LS8 2PA 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) 0113 2658398 0113 2323025 cartelin@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd Care Home 49 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (49), of places Physical disability (1) Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The places for DE(E) and PD are specifically for the service users named in connection with the variation application date 23/6/4 9th March 2006 Date of last inspection Brief Description of the Service: The home comprises of two buildings. Oakwood House dates back to the 19th century whereas Park House was purpose built more recently. The home is situated in a quiet location close to the main shopping area at the north end of Roundhay Road. Roundhay Park is also nearby and the home is close to a number of bus routes into Leeds and to surrounding areas. The home is registered for 49 places for older people with one place for a named young physically disabled service user and one for a named service user with dementia. Accommodation is provided mostly in single rooms, the majority of which have en-suite facilities. There are some shared rooms available all of which have en-suite facilities. Personal care with nursing is provided. There are spacious communal lounges and dining rooms in both houses and access to the attractive gardens and patio is by ramp or level access. Passenger lifts go to all floors accessed by service users. Information about the service and facilities is available in a statement of purpose and service user guide as well as a home brochure. The current charges range from £380 to £720 per week. Additional charges are made for chiropody, hairdressing, aromatherapy and newspapers. This information was included in the pre-inspection questionnaire completed by the provider in February 2007. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way care services are inspected. They are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate”, and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes and copies of past inspection reports are available on our website – www.csci.org.uk Information about the home is gathered from a variety of sources, one being a site visit. Additional site visits may be made that will concentrate on specific areas such as health care or nutrition called random inspections. One inspector carried out this inspection on 12th March 2007 and was at the home from 09.40 until 18.20. The purpose of this inspection was to assess all the key standards (the key standards are identified in the main body of the report); to assess progress in meeting any requirements made following the previous inspection and to assess how the needs of people living in the home are being met. The methods used at the inspection included looking at care records, talking to residents, observing care practices in the home, talking to staff and management, looking at the environment and looking at other paperwork including staff records. The home provided some information to the CSCI in advance of the inspection. Comment cards were left at the home for residents and their relatives. Survey cards were sent out in advance of the visit to General Practitioners and other visiting healthcare professionals. None had been returned at the time of writing the report. What the service does well: The home is conveniently positioned for access to a range of local amenities. The home overlooks large well maintained gardens which are accessible to the residents. Many of the bedrooms overlook the gardens as well as the comfortable communal areas. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 6 The staff are smart and professional and welcoming to visitors. They demonstrate patience and respect towards the residents. The manager has good communication skills and works with her staff in running the home in the best interests of the residents. There are established audit systems at the home which help the manager to make sure that services and facilities at the home are monitored and maintained at a good level. There is a commitment to making sure that staff are properly trained and can effectively care for the residents. This includes National Vocational Qualifications (NVQ) for care staff. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Sabourn Court Nursing Home DS0000001369.V327087.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 Sabourn Court Nursing Home DS0000001369.V327087.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is enough information for current and prospective residents to help them decide about moving into the home. All residents have their needs assessed prior to admission to the home so that they know that they will be looked after properly. EVIDENCE: Information about the service is available to current and prospective residents. There is a statement of purpose, service user guide and home brochure. An information pack is provided in every bedroom. This pack was in the process of being reviewed and updated to reflect the managerial changes at the home. The manager carries out pre-admission assessments of prospective residents so that she can be sure that care needs can be met at the home. In addition Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 9 to the home’s assessment, information was gathered from other sources for example hospital discharge letters. It was suggested that the pre-admission assessment could be enhanced by the addition of who was involved in the assessment, where it took place and how long it took. Sabourn Court Nursing Home DS0000001369.V327087.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in place providing information about how care needs can be met. The detail in these plans is not always specific and provides the opportunity for some care needs to be overlooked. Medication practices are safe. EVIDENCE: Care plans are in place for all the residents. A selection of individual care records was looked at from both Park House and Oakwood House. All the records have clear photographs of the residents. 24-hour life plans are included in the records and these provide a good and detailed overview of how the individual likes to spend their day. However, care must be taken to update these plans when significant changes occur to make sure that the information is accurate and up to date. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 11 One resident had been admitted to the home with their spouse and had been reliant on them for some of their care needs. Following the death of the spouse care plans the 24-hour life plan and care plans had not been reviewed and re-written to reflect this major change in circumstance. The resident did feel supported by staff and was content at the home feeling that staff understood their needs. There is a range of risk assessments carried out for every resident and these include a falls risk assessment and one for the risk of skin damage. The manual handling risk assessment includes a management plan with instructions about the input needed from staff, the equipment needed and the number of staff required to safely assist the resident. In one set of records there was signed consent from relatives for the use of bed safety rails but no risk assessment for their use. The care plans for a recently admitted resident did not always provide clear instruction for staff. For example, a care plan for the management of diabetes said ‘observe for the signs of hyperglycaemia and hypoglycaemia’ without any indication of what these might be. In the case of another resident, there has been a great deal of work undertaken by the manager and her staff to achieve compliance with care. The care plans did not provide evidence of the negotiation or of the agreement of the resident. Some good evaluation of care plans was seen and there were also some good social care plans seen. The manager was given full feedback about the records. There is a commitment from the manager to improve the records and new documentation is to be introduced by the provider with the intention of addressing any shortfalls in recording. Medication administration record (MAR) sheets showed some gaps in recording where no code had been used to explain the omission. The medication room on Oakwood House is a rather cramped area but was clean and tidy. Regular audits of the medication system are carried out and all staff involved in the administration of medication have an annual update. Staff demonstrate respect for the residents and protect their privacy. Sabourn Court Nursing Home DS0000001369.V327087.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents exercise choice in their everyday lives and a good varied diet is offered which takes individual choices into account. Residents are encouraged to maintain links with their friends and family and visitors are welcomed into the home EVIDENCE: There is a new activities organiser employed at the home who is beginning to develop a regular programme of activities for the residents. As part of this he has already produced a three-month agenda of planned events and activities. This will be done regularly throughout the year, for example, the January to March programme was available at the beginning of December and in March the April to June programme was distributed. Social evenings are held every six to eight weeks with the most recent on 14th February. Plans were well underway to celebrate Mothers’ day and Easter. The activities organiser works five days a week from 10.00 until 15.00 although there is some flexibility if, for example, evening or weekend events are planned. The manager is working with him with regard to record keeping and he is to attend a study day on activities in May. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 13 Visitors are welcomed at the home at any time and those residents who are able, go out where possible. Residents are supported to spend their time how they wish and some choose to stay in their rooms while others spend their time in the lounges. The lunchtime meal was observed in Oakwood House. The majority of the residents ate their meal in the very attractive dining room. The food looked and smelt attractive and residents were seen to be enjoying their food. Sabourn Court Nursing Home DS0000001369.V327087.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately and systems are in place to protect residents from abuse. EVIDENCE: There is a clear and robust complaints procedure, which is displayed in the home. Monthly returns are sent to head office recording any complaints or compliments received. A number of compliments had been received about the care provided at the home, including, ‘a pleasure to see the kindness of the staff and the contentment of the residents’. Records show that the manager deals promptly and appropriately with complaints received. The response to a recent complaint was copied to the CSCI. It demonstrated a thorough investigation and detailed response to the complainant. The manager has attended adult protection training provided by the local authority that enables her to train staff. Information provided before the visit states that almost 100 of staff will have received the training by mid February 2007. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents live in a safe and well-maintained environment. EVIDENCE: All the areas of the home visited were clean and fresh smelling. The communal areas are situated on the ground floor of both houses and are comfortable and spacious. There is a small, dedicated area identified for smokers in Oakwood House. Bedrooms are furnished to a high standard with larger and more spacious rooms in Oakwood House. There is an attractive outside seating area overlooking the gardens, which is very well used by the residents in the good weather. The grounds are being Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 16 cleared at the back of Park house to increase the area which can be used by residents and to develop a sensory garden. The laundry was clean, tidy and well organised with a range of equipment all of which was in working order. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are sufficient to meet the needs of the residents. There are good recruitment procedures in place to protect residents. EVIDENCE: The duty rotas indicated that there are enough staff to meet the needs of the residents. An established team of domestics, laundry and maintenance staff, as well as an administrator provide support for the nurses and care staff. Information provided in advance of the visit states that 84 of care staff have achieved a National Vocational Qualification (NVQ) in care at level 2. New staff have a two day intensive induction course before starting work at the home. They then continue their learning by working through the ‘Skills for Care’ workbook which they complete within at least six weeks. There is a comprehensive training programme and the new manager has identified and prioritised areas of training since she has been at the home. The training provided makes sure that staff are equipped to properly meet the needs of the residents at the home. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 18 A sample of staff recruitment files was looked at and the recruitment practices were found to be satisfactory. The company is introducing new staff files that are providing the opportunity for a complete review and audit of the information held for all staff. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed. The interests of the residents are seen as very important to the manager and the staff. EVIDENCE: The manager has been at the home for just a few months after transferring form one of the sister homes in the Leeds 8 area. She is an experienced and enthusiastic nurse who has completed the Registered Managers Award. After some initial difficulties with the change in management at the home she has started to prioritise and work towards improvements in the quality of life for the residents. There is monthly audit of the accidents to help identify any trends or issues that could be contributing to accidents. This information is shared with head Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 20 office as part of the monthly returns on a range of issues including incidents of skin damage and complaints. There is a well established system of audits in place which are used as part of the in house monitoring systems to make sure that good standards are maintained and any shortfalls identified and addressed. Some of the areas forming part of this ongoing audit are care planning and medication administration. There is a regular system for staff meetings and notes of these are kept. Meetings are also held with relatives but due to poor attendance the manager is reviewing the need and attendance for these. The manager has good communication skills and makes herself available to residents and relatives. A letter in the compliments file described the manager as ‘very professional, helpful courteous understanding and supportive’. There is a policy of not handling residents finances and any additional costs such as hairdressing are invoiced. A small number of residents are supported in handling their own finances. Mandatory training is ongoing for all staff and there are four fire trainers to facilitate this. There will also be four in house manual handling trainers, which will also make manual handling training more accessible and flexible. Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 21 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 22 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. 1 Refer to Standard OP7 Good Practice Recommendations The manager should make sure that the information in the care plans is relevant and up to date to make sure that care needs are not overlooked. The manager should continue to work with her staff in developing a more person centred approach to care planning. A review of the storage facilities for medicines should take place to establish whether more suitable facilities can be provided. 2 OP9 Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Sabourn Court Nursing Home DS0000001369.V327087.R01.S.doc Version 5.2 Page 24 - 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. 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