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Inspection on 24/02/09 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 24th February 2009.

CSCI found this care home to be providing an Adequate service.

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 situated in large well maintained gardens which are accessible to people living at the home. It is also conveniently positioned close to a range of local amenities. The staff are smart and professional and welcoming to visitors. They demonstrate patience and respect towards the people they care for.Sabourn Court Nursing HomeDS0000001369.V374539.R01.S.docVersion 5.2There is a commitment to making sure that staff are properly trained and can effectively care for people. This includes National Vocational Qualifications (NVQ) for care staff.

What has improved since the last inspection?

A local authority grant has enabled the home to develop an area of the garden into a comfortable seating area and it includes some raised flower beds.

What the care home could do better:

Information about the home needs to be reviewed to make sure that it accurately reflects the service and facilities provided. This is so that people are clear about what to expect when they move into the home. Information in the care plans about care needs and support must be relevant and up to date. This is to make sure that staff have access to clear information about how to look after people, so that care needs are not overlooked as they change. Risk assessments need to be fully completed and updated regularly. This is to make sure that people are safe and any identified risks are properly managed. We received mixed views on the provision of food. A full review of the provision and availability of food needs to take place. This is to make sure that people are being provided with adequate quantities of suitable, wholesome and nutritious food available at times when they want it. A more proactive approach should be taken to dealing with complaints and concerns so that people feel more confident that they are being listened to. Requirements and recommendations made as a result of this visit 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 24th February 2009 09:20a 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.V374539.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.V374539.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 ibrahisj@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 49 The maximum number of service users who can be accommodated is: 49 12th March 2007 2. 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 £558 to £1000 per week. Additional charges are made for chiropody, hairdressing, aromatherapy and newspapers. This information was provided at the February 2009 inspection. The home should Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 5 be contacted directly for up to date information about fees. This information was included in the pre-inspection questionnaire completed by the provider in February 2007. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit by one inspector who was at the home from 09:20 until 16:05 on the 24th February 2009. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the staff and representatives of the provider. The registered manager was not available at the time of the visit. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a selfassessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home, visitors and healthcare professionals who visit to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned by the time of this visit. Comments received appear in the body of the report. What the service does well: The home is situated in large well maintained gardens which are accessible to people living at the home. It is also conveniently positioned close to a range of local amenities. The staff are smart and professional and welcoming to visitors. They demonstrate patience and respect towards the people they care for. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 7 There is a commitment to making sure that staff are properly trained and can effectively care for people. 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.V374539.R01.S.doc Version 5.2 Page 8 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.V374539.R01.S.doc Version 5.2 Page 9 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) People who use the service experience adequate quality outcomes in this area. People were provided with information about the service but it did not always accurately reflect the service provided. Everyone has their needs assessed before being admitted to the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “Comprehensive written information is provided to all prospective clients, outlining the ethos of Bupa Care Homes and the home, as well as vital information to help with the process of choosing a care home. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 10 The home’s CSCI reports, the Service User Guide and Statement of Purpose are made available in reception. Prospective residents who are unsure are given the option of a trial in the home, to ensure their happiness and wellbeing. Regular mystery shops are conducted to ensure the home is providing the correct information to enquirers. All required staff undertakes enquiry training within Personal Best Training. We provide details of other Bupa homes in the area. We actively encourage enquirers to look at other homes so an informed decision can be made.” Some people said that they had received enough information about the home before they moved in. Others said that information about the home did not match their experiences when they moved in. People said – “The information that was given about the care I could expect and activities on offer, did not match with my experience after moving in.” “Totally disillusioned with what a nursing home is supposed to be. There are no outings. What happened to quality of life? And dignity that goes with it” There is an established system of the assessment of people’s care needs before they are admitted to the home, shortly after admission and on a regular ongoing basis. At the initial pre-admission assessment information is also gathered from other healthcare professionals. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 11 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 People who use the service experience adequate quality outcomes in this area. Care plans were in place providing some information about how care needs can be met. The information in these plans was not always up to date. This means there is a risk of some care needs being overlooked. People are protected by safe medication procedures. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “All residents have comprehensive Personal Plans produced with the help of the QUEST assessment tool, which are reviewed monthly and updated as necessary. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 12 The Royal Marsden Manual is available to staff. Regional and National specialists are available for consultation. We record and report on the treatment of pressure ulcers, as well as assess and document actions taken to alleviate the risk. All residents’ nutritional needs are assessed using a recognised nutritional assessment tool. All residents are registered with their choice of GP. Resident care is focussed on being person centred, supported by the Personal Best Programme. Monthly audits are conducted by the regional manager assessing many aspects of care to allow continual quality assessment and improvement. This is in addition to the Reg 26s and also detailed audits on specific aspects of care done at Home level (medication, care planning etc). A regular overview on the quality of resident care is provided by the regional manager, regional director and the Quality and Compliance team. The Key Operating Guides have been developed to ensure best practice in selected aspects of care, giving the required information at point of delivery. There are comprehensive policies and procedures which are regularly reviewed. The BNF is available for use. Audit framework for care records. We looked at a small selection of the care records in detail. We found that care plans were not up to date and did not always provide staff with the relevant information about how to look after someone properly. One person’s care plans had been written around the time of admission and had not been updated to reflect changes. For example, one care plan dated from July 2007 referred to this person having a ‘low mood’ but that they would probably ‘be alright when settled in’; another referred to the lifting sling being too small and had not been updated since a more suitable sling had been purchased. Information about personal hygiene was also unclear. The care plan stated that this person had a weekly bath ‘every Saturday’. This person told us that they had only had one bath since moving into the home. Monthly reviews were not detailed and did not provide evidence of the effectiveness of the care plans over the previous month. Risk assessments are completed for people but some were seen to be out of date and were in need of review. For example, one manual handling Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 13 assessment had not been reviewed since 2007 and did not reflect the current situation. We saw a risk assessment for self-medication administration that was unnamed, undated and unsigned. The risk assessment sheet for the risk of skin damage was a very poor photocopy and illegible. We saw daily records that did not provide detail of the heath and wellbeing of the person. We also saw that gaps had been left on daily recording sheets where staff had not completed the record. Incomplete and out of date records mean that there is a risk of care needs being overlooked. One person said to us “they don’t know about me at all” and “XXXX is marvellous, combs my hair, puts cream on my face – some can’t get out of the room fast enough.” There was some relevant information in this person’s care plans but they felt that some staff did not understand how to look after them properly, for example, that, due to arthritis it hurt when staff touched them. One person had been admitted to the home for palliative care. This person felt that there were a number of staff who did not understand how to care for him properly and that there were not enough specialist staff although they did say that night staff were ‘excellent’. This person’s mobility had deteriorated with progression of their illness. Information recorded in care plans did not indicate that staff really understood this person’s condition. For example, the evaluation of the mobility plan just stated ‘still could not weight bear’. We were told by some people, who were no longer mobile, that they were not able to have a bath or shower, as facilities were not suitable for more dependant people. People said – “Sometimes…. there are not enough female carers” “New staff do not seem to be properly briefed about my condition and the care I need.” “Sometimes I have to wait a long time for the toilet.” (Care and support) “Too hit and miss. Not enough staff” “Staff are good and willing” There were records of the input from other healthcare professionals. We received completed surveys from some of the healthcare professionals who visit the home and their comments were mixed. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 14 Healthcare professionals said – “…inappropriate/excessive calls to GP practice and communication between staff/shifts is not comprehensive. But staff do act upon Drs advice.” (meeting in 2008) “Unfortunately failed to achieve any improvement.” “Staff are often stressed and comment on being too busy to do the job.” “privacy and dignity is mostly respected.” (How can the service improve?) • “Communicate with GP practice • Increase the qualified staff on duty Regular audits of the medication system are carried out and all staff involved in the administration of medication have an annual training update. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 15 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 People who use the service experience adequate quality outcomes in this area. People are supported to make choices about how they spend their time. The provision of activities and stimulation was limited and did not meet the expectations of some people. People are not always provided with the variety of food they expect at the times they want. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “We ensure that all Personal Plans are individual and based on the choices and preferences of the residents. Should they choose to do so, residents are encouraged to handle their own finances. We encourage the personalisation of a resident’s personal space, giving Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 16 somewhere they can really feel at home. We have developed our menus to allow for resident choice and preferences. We employ an open visiting policy, taking into account residents wishes. The menu master helps ensure every menu within the home is customer led and nutritionally balanced. The ‘Nite Bite’ menu allows our residents to choose what to eat when they feel like it, providing healthy choices at any time through the night. We provide picture menus to help open up choice. We encourage the involvement of residents and staff in the development of the menus. We have a structured activities programme, with a dedicated activities organiser. We encourage a weekend activities programme. People spend their time either in their rooms or in the main lounge areas. A number of people were dozing or just staring into space with the television on but few were taking notice of it. There is an activities person but activities are limited in that the afternoon game of bingo took place in Park House meaning that there was nothing going on for people in Oakwood House. People said: “There are no activities in Sabourn Court to encourage or inspire any of the residents of any age.” “There are activities, but they are not the type I want to take part in.” Visitors are made very welcome at any time and those who are able go out with their friends and family. Other people spoke of the fact that they did not get the opportunity to go out although this had been an expectation when they moved into the home from information they had been given. The gardens have been improved with the use of a local authority grant and there is an attractive seating area with raised beds and a pond. We saw that some people had refrigerators in their bedrooms. People told us this was so that they could have food and snacks of their choice throughout the day. Feedback given to us was that the ‘Nite bite’ menu is not available to people and overnight staff cannot provide people with drinks or snacks. One person had wanted some squash and another some toast and both were told that this was not possible as staff did not have access to the kitchen overnight. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 17 General comments about food were mixed with people saying it was ‘bland and unappetising’. Another person spoke of the problems of making menu choices the day before. This meant that if they wanted a cooked breakfast this was not a decision that could be made at breakfast time but had to be made the day before. On the day of our visit the lunchtime meal did not smell appetising while it was being cooked. There was an unpleasant greasy smell. However, at lunchtime the food looked attractive and people seemed to enjoy it. The lunchtime meal was a busy part of the day with several people needing significant help and support to have their meal. One member of staff had to assist several people and was not able to concentrate on one person. The management of the mealtime should be looked at in an attempt to make it a more pleasant and relaxed experience for people. People said – “Breakfasts are always lovely but getting vegetarian main meals is difficult.” “The gap between breakfast and lunch is too short now the kitchen staff hours have been cut. Breakfast doesn’t come now until 9.20 – (rather than 8.45) and then lunch is just after 12 (about 12.15). Lunch needs to be later or breakfast earlier” “We need a qualified chef and better variety of menu.” “Evening snacks very poor.” “The food is bland.” “We have been given new menus but the food doesn’t live up to the descriptions.” This information was fed back to the provider the day after the visit and we were given assurances that these issues would be looked into. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 18 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 People who use the service experience adequate quality outcomes in this area. There was a complaints procedure in place but people did not always feel listened to and or that any concerns are taken seriously and acted on. People are protected by staff awareness of safeguarding procedures. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – Bupa Care Homes is currently reviewing its current complaints policy. The current policy has agreed timescales for managing complaints. The information that accompanies the policy is prominently displayed in the home. The policy includes a three – tier framework including the home, the regional management team and the national Quality and Compliance department. Bupa Care Homes has robust allegation of abuse and neglect policies, allowing staff to raise concern within the home or to senior staff outside the home. The PoVA procedures are well documented should the need arise. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 19 Whistleblowing policy. Bupa Care Homes has a national team of Quality and Compliance experts available to provide advice and help where needed. Training is available regarding to all aspects of protection. There is a well established complaints procedure in place at the home that is made available to people. In the absence of the manager on the day of the visit we did not have access to detail about complaints received. We saw the completed log that showed the dates complaints were received and the dated by which they had been dealt with. This indicated that they had all been dealt within the timescale noted in the procedure. We received a small number of concerns from people since the last visit in 2007. These were referred to the provider and information provided to us indicated that concerns had been taken seriously and dealt with properly. However, information from our surveys before this visit produced mixed views from people about making their concerns heard at the home. People said – “I know who to speak to (if I am not happy), but it doesn’t always make any difference.” (I know who to complain to) “But a waste of time – action not taken without a fight” (I know who to complain to) “Think it might be the head nurse but don’t like to complain” Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good quality outcomes in this area. People live is a safe, comfortable and well maintained environment. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “We use a specialist micro fibre cleaning system that combined with effective cleaning regimes keeps the home clean and odour free. Our comprehensive policies and procedures include infection control and handling clinical waste. Services and facilities comply with the Water Supply (Water Fittings) Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 21 regulations. The home is supported in maintaining the environment by a central team of experts. We have a specialist property and estates department as well as a hotel services department. Regional Managers visits focus on the standard of housekeeping. EHO Inspection December 2008 4*” We visited all areas of the home used by the people who live there. The home was clean and odour free. People said – “Repairs have not been carried out eg. the sash window in my room has been broken since before I moved in (2007). The control on the radiator is broken and fastened up with tape” “The cleaning is adequate” “Sometimes bad drain smells coming from the bathroom” “Very good cleaners” There are good infection control systems in place and all the staff have had training in infection control procedures. There is an attractive outside seating area overlooking the gardens, which is very well used by people in the good weather. The grounds have been cleared at the back of Park House to provide an additional outside seating area. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good quality outcomes in this area. Trained and competent staff care for people. Robust recruitment practices protect people. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “Bupa Care Homes has comprehensive Human Resource policies and procedures to aid staff management and recruitment. We endeavour to maintain agreed staffing levels at all times. We perform appropriate CRB, PoVA and NMC PIN checks on all staff. There is a training matrix specific to the home that identifies the training requirements of staff. We have a good level of staff retention. We have a unified style and format for staff files. We have an improved skill-mix. All mandatory training is up-to-date. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 23 Comprehensive Whistleblowing Policy. Bupa Care Homes has received IIP accreditation and it has been reviewed since 2003.” The manager was not available on the day of the visit. The nurse in charge of Park House usually worked the night shift. Oakwood House was staffed with the regular team. The home appeared organised, although staff were busy and did not seem to have much time to sit and talk with people. Staff said that they felt that there were enough staff to look after people and that when they were under pressure additional staff were provided. An established team of domestics, laundry and maintenance staff, as well as an administrator provide support for the nurses and care staff. The staff we talked to all said that they felt well supported and that there was plenty of training available to them to make sure that they knew how to care for people. Staff said – (Training) ..is excellent covering fire, COSSH, Health and Safety, Manual Handling. There is also a learning portfolio Housekeeping/Laundry Induction Programme.” “Every 2 months we have a supervision discussion.” “Every year appraisals are given.” We looked at recruitment files for recently employed staff. All the required checks are completed before people start work at the home. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 24 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 37 and 38 People who use the service experience adequate quality outcomes in this area. Overall, the service is run in the best interest of the people who live there but on occasion their interests can be overlooked. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “Regular Health and Safety meetings take place, with a standardised Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 25 agenda giving staff the opportunity to communicate on Health and Safety issues. The minutes from there go to the Regional Manager and Quality and Compliance team. There are regional and national experts available within the company for advice and guidance if required. The Home is supported by a national team of Quality and Compliance Officers whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. There are dedicated Health and Safety staffs within the regions, supported by a National Quality and Compliance team. This includes Health and Safety and Fire Management Leadership. Bupa Care Homes has a comprehensive suite of policy and procedure manuals that are regularly reviewed by experts and updated when required. We have an annual internal and external customer satisfaction survey. Bupa SOP (Surveying Our People) is conducted annually. The Personal Best programme encourages a person centred approach to all tasks. Staff meetings occur monthly. All staff is supervised. The manager is a qualified nurse who has also completed the Registered Managers Award (RMA). Although she has been managing the home for some time she has not yet completed her application to be registered. There is an established system of in-house audits completed by the manager that highlight any shortfalls. The audits we looked at for January 2009 and February 2009 showed some issues being carried forward from month to month. For example, one person had told us that they had been told that a Newsletter was to be produced; the audit outcomes identify that it is to be done but note it as ‘pending’ but with no indication that this was to happen anytime soon. ‘Drop in’ sessions with the manager were noted as ‘to commence’ in January but had not, with no indication of any projected start date. There had been a Relatives/Residents meeting held at the beginning of January but the notes of this meeting had not yet been made available to everyone. People said – “Since my mother moved into the home in mid 2008 we have never seen the manageress or had any contact with her about my mother whether she has Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 26 settled in:- but we do have good contact with the nursing staff on a twice weekly visit by us” Staff said about what the service could do better “More staff meetings = quicker at resolving any probs/queries within workforce” “Increased manager interaction with service users/staff” “More ‘hands on’ ‘working the floor’ by manager” It was of some concern that care records had misguidedly been made available to someone who was not employed at the home and who did not have legal access to them. This person did need some information about how to approach people but this should have been communicated verbally and this person should not have had access to records. This concern was shared with the provider, who was not aware of this arrangement, for them to take the appropriate action to make sure that records were secure. Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 27 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 3 Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 28 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. 1 Standard OP7 Regulation 15 Requirement Information in the care plans about care needs and support must be relevant and up to date. Timescale for action 18/05/09 2 OP8 13(4) This is so that care needs are not overlooked as they change. Risk assessments must be fully 20/04/09 completed and updated regularly. This is to make sure that people are safe and any identified risks are properly managed. A full review of the provision and availability of food must take place. This is to make sure that people are being provided with adequate quantities of suitable, wholesome and nutritious food available at times when they want it. 3 OP15 16(i) 18/05/09 Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 29 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 OP1 Good Practice Recommendations The information made available to people should be reviewed. This is to make sure that information provided accurately reflects the service and facilities provided at the home. Staff should work at developing a more person centred approach to care planning and the evaluation of care plans. This will make sure that people are looked after in the way they want. The management of mealtimes should be reviewed to make sure that people are being given the support they need in a relaxed and unhurried environment A more proactive approach should be taken to dealing with complaints and concerns so that people feel more confident that they are being listened to and that action is taken. 2 OP7 3 4 OP15 OP18 Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 30 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA Telephone: 03000 616161 Fax: 03000 616171 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk © This report is copyright Care Quality Commission and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CQC Sabourn Court Nursing Home DS0000001369.V374539.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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