Inspection on 20/10/05 for Sabourn Court Nursing Home

This inspection was carried out on 20th October 2005.

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

Sabourn Court Nursing Home 24/02/09

Sabourn Court Nursing Home 12/03/07

Sabourn Court Nursing Home 09/03/06

Sabourn Court Nursing Home 08/02/05

Sabourn Court Nursing Home 24/08/04

Sabourn Court Nursing Home 09/03/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Sabourn Court Nursing Home Oakwood Grove Leeds Yorkshire LS8 2PA Lead Inspector Catherine Paling Unannounced Inspection 20th October 2005 10:30 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.V255816.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. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 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 BUPA Care Homes (GL) Ltd Shirley Lesley Dolan 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.V255816.R01.S.doc Version 5.0 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 8 February 2005 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. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the first inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on 8 February 2005. This was an unannounced inspection carried out by two inspectors who were at the home from 10.30 until 16.30. The main purpose of this inspection was to make sure that the home provides a good standard of care for the service users and to assess progress on meeting any requirements or recommendations made at the last visit. The methods used at this inspection included looking at care records; observing working practices and talking to staff, service users, relatives and to the manager. What the service does well: What has improved since the last inspection? What they could do better: The manager must make sure that all residents have their needs fully assessed prior to being admitted to live at the home. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 6 The manager needs to make sure that the care records are an up to date and detailed reflection of the needs of the residents. She must also ensure that all the information within the records is legible. Care plans must provide staff with clear and specific instructions. Residents and/or their families should be involved in the development of the records wherever possible. Communications with relatives as well as healthcare professionals should be evidenced within the records. Staff need further guidance in assessing potential risks to residents. Where risk is identified care plans must provide instruction on how the risk is to be managed. The manager should make sure that staff responsible for fitting bed safety rails are properly trained. Requirements and recommendations have been made and can be found at the back of the report. 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. Sabourn Court Nursing Home DS0000001369.V255816.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 Sabourn Court Nursing Home DS0000001369.V255816.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 and 5. (Standard 6 is not applicable). Not all residents have their needs fully assessed before moving into the home and cannot therefore be assured that their needs will be met. Prospective residents have the opportunity to visit the home to help them make an informed choice about the home. EVIDENCE: The standard of pre-admission information varied considerably. Some preadmission information seen was satisfactory with some very brief. One seen did not contain sufficient information to demonstrate why the decision had been made that needs could be met at the home or if any specialist equipment was needed. In the case of one resident it was not clear how she had come to be admitted to the home at all. There was little or no information on the Easycare document and the home had not conducted its own assessment of need. Daily records referred to this resident’s placement becoming permanent but there was no rationale on how or why it had been decided that the home could Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 9 meet her needs. Daily records also indicated that there could be some mental health issues. These had not been explored prior to admission. One recently admitted resident and his daughter told how being able to visit the home prior to admission had helped them choose. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 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 and 10. Care plans do not provide clear and detailed instructions for staff providing the opportunity for care needs to be overlooked. Staff treat the residents with respect and maintain their privacy, showing an awareness of their needs. EVIDENCE: All residents had care plans in place. A selection of individual records was looked at from both Park House and Oakwood House. The standard of recording was variable with some good detail seen but in some cases the written information was illegible. If information within the records is not clear it could result in care needs being overlooked. Some of the care plans of a resident who had been at the home for some years had not been rewritten for over twelve months and there was no evidence of a full review of care needs involving the resident and their representatives. Not all identified needs had care plans to provide instructions for staff. For example a resident who had an indwelling catheter following urinary retention had no specific information about this and some was impossible to read. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 11 Instructions such as ‘give enough fluid intake’ or ‘refer if needed’ without any specific detail of what is meant are not acceptable for a resident who had suffered an acute problem. Although this resident had a fluid chart it was evident from this chart that the fluid intake was not adequate and there was no chart for the day of the visit. Where there were clear instructions for staff such as checking a dressing after three days this had not been done. A falls risk assessment was being carried out but there was no specific plan of management to indicate that staff were taking all the precautions possible to protect the resident who were falling. One resident had suffered a fracture following a fall and records indicated that they were falling regularly. There was no evidence that the risk and any plan of management was being reviewed after each fall or that such interventions as hip protectors had been considered. This resident appeared to have some mental health issues and there was no evidence that these were being addressed. None of this resident’s care plans had been updated following the fracture when clearly the support needed from staff had changed. Bed safety rails were in use for some residents but there was no risk assessment to provided a rationale for their use. In addition the wrong type of safety rails were found in use on two beds. There was poor information in one care plan about the nutritional needs of one resident with vague instructions such as ‘to watch meal intake’ and ‘to provide small snacks in between’. This resident had a particularly low weight. The plan had been written in June and was not reviewed until August. There was no food diary being used to properly monitor their intake. Although a specialist mattress was in used for one resident, it was not recorded in the records and was incorrectly set. Records of GP visits were seen with detail of the outcome of their visits. Records were not seen of the involvement of other healthcare professionals. Records did not always indicate that relatives were being kept informed of changes although one relative said that she felt that she was kept informed. From observation and comments made by residents and relatives, staff respect the privacy and dignity of the residents. Some staff approached residents in a manner indicating an understanding of their needs. Others did not provide residents with clear indication of what was happening when they took them through to the dining room for lunch. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 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 and 15. Residents are encouraged to maintain links with their friends and family and visitors are welcomed into the home. Residents are offered a varied and nutritious diet. EVIDENCE: Residents are encouraged to maintain contact with their friends and family. Visitors are welcomed at the home at any time and are able to take the residents out if they wish. One resident and her visitor were seen to be enjoying a walk in the attractive grounds during the time of the inspection. Another resident spoke of a trip to a shopping centre and about the entertainment at the home. Another resident said that she was not bothered about entertainment and could entertain herself. At the time of the visit it was noted that the programme of activities displayed in Park House was out of date. The lunchtime meal was observed in Park House. The dining area was set out attractively. The tables were laid with cloths, tablemats and table decorations. Residents were given a choice for each of the three courses. Squash and tea were served with the meal. Assistance was given on a one to one basis as needed in a discreet and unhurried manner. During the afternoon there was a cup of tea and homemade cake or a biscuit offered to all the residents. Sabourn Court Nursing Home DS0000001369.V255816.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): EVIDENCE: None of these standards were assessed at this visit. Sabourn Court Nursing Home DS0000001369.V255816.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. The residents live in a safe and well-maintained environment. EVIDENCE: Since the last inspection there has been a major refurbishment and redecoration of the communal lounge and dining facilities at Park House. These areas now reflect the high standard of decor seen in Oakwood House. The refurbishment of Park House should continue to include the bedrooms and communal sanitary facilities. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 15 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. There were adequate numbers and overall an appropriate skill mix of staff to meet the needs of the residents. EVIDENCE: Rotas indicated that there were sufficient staff on duty to meet the needs of the residents. The total numbers remain reasonably constant although there is sometimes a difference in the skill mix of staff on duty. A small number of agency staff are needed on a regular basis to maintain adequate numbers of staff. Care staff are supported in their work by domestic, catering and laundry staff. There is also an administrator based at the home. The home is currently without a maintenance man and this role was being covered from the sister homes close by. The manager’s hours of work were not included on the rota and should be. Staff training records were not looked at during this visit. However the manager said that she was developing a training matrix to allow easy reference to who had done what training. She also said that she was aware that fire training was not yet up to date but that she had now completed a course to allow her to train the staff in fire safety. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 16 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 and 38. The manager does not always provide clear leadership, guidance and direction to staff to ensure that residents receive a consistently good level of care. This results in some practices that do not promote and safeguard the health safety and wellbeing of the people using the service. EVIDENCE: All resident accidents were recorded but unwitnessed accidents did not include the time of when the resident had last been seen prior to the accident. There was no information of how the resident was recovered from the floor. When accidents were cross-referenced with the daily records there was no evidence to suggest that relatives had been informed. At the time of the visit the manager was advised to check all the bed safety rails currently in use to satisfy herself that the correct type were in use for the Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 17 bed. In addition, the value of additional in-house training regarding the fitting and checking of bed safety rails should be considered for all staff involved. The visitors and residents spoken to during the visit said that communications were good. They were aware of the relatives meetings although not all attended and one said that they felt that they were a waste of time. This was because it was felt that no action was taken to resolve issues raised at the meeting. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 18 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 1 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 19 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 OP3 Regulation 14(1) Requirement Timescale for action 02/01/06 2 OP8OP7 15(1) All residents must have their needs fully assessed prior to admission to the home by a suitably qualified person. Care plans must set out in detail 06/02/06 the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met. Care plans must be drawn up with the involvement of the service user and agreed and signed by the service user whenever capable and/or their representative. (previous timescale 15/06/06 not met) 02/01/06 Unnecessary risks to the health or safety of service users must be identified. Risk assessments must identify any risk and detail the action that needs to be taken to reduce the risk. (previous timescale of 15/06/05 not met) All staff must complete the 06/03/06 TOPSS (Training Organisation for DS0000001369.V255816.R01.S.doc Version 5.0 3 OP7 13(4)(c) 4 OP30 18(1)(c)(i) Sabourn Court Nursing Home Page 20 Personal Social Services) foundation standards within the first six months of employment. All staff must receive moving and handling training at intervals of no more than twelve months. 23(4)(d) All staff must receive fire training at intervals of no longer than six months. (carried forward from 08/02/05) 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 OP7 OP31 OP38 Good Practice Recommendations Records should evidence communications between the home and relatives as well as other healthcare professionals. The manager should review her systems for monitoring practice to make sure that she consistently provides clear guidance and leadership to safeguard the residents. Where an accident is not witnessed, a record should be maintained of when the person was last seen and by whom. Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Sabourn Court Nursing Home DS0000001369.V255816.R01.S.doc Version 5.0 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. 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