Inspection on 09/03/06 for Sabourn Court Nursing Home

This inspection was carried out on 9th March 2006.

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 20/10/05

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 9th March 2006 09:50 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.V284550.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 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 www.bupa.co.uk 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.V284550.R01.S.doc Version 5.1 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 20th October 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.V284550.R01.S.doc Version 5.1 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 second 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 20 October 2005. This was an unannounced inspection carried out by two inspectors who were at the home from 09.50 until 17.20. 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. Comment cards were left at the home for residents and visitors to complete if they wish. Any comments received would be shared in confidence with the home. A small number have been received from both residents and from visitors. Overall positive comments have been made with one resident describing a ‘pleasant, caring environment’ and all those comments received stating that they felt well cared for. Relatives/visitors comment cards were also positive saying that ‘all staff are kind’ and one ‘glad we chose Sabourn Court’. However one relative/visitor suggested that more stimulation ‘would be very welcome’ and gave examples of music to sing along to for a short time each day. What the service does well: The home continues to provide a welcoming atmosphere and staff are smart and professional in their approach. Visitors are made very welcome and are offered refreshments. One visitor sits with his wife every afternoon and said that staff make him feel at home. Pre-admission assessments are carried out for all prospective residents to make sure that the home can meet their needs. The gardens are well-maintained and provide an attractive outlook from many of the rooms. The manager works hard at involving the residents in such things as reviewing the menus. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 6 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. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. (Standard 6 is not applicable). All residents have their needs assessed before admission to the home so that they can be assured that these needs can be met. EVIDENCE: The manager or senior members of the nursing team carry out detailed preadmission assessments. The detail in one of the examples seen was brief. The manager said that there was a new format in use. There was more detail and information in an assessment carried out using the new format. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 9 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 9. 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. There were some medication practices, which provided the opportunity for error to occur placing the residents at potential risk. EVIDENCE: A small number of residents records were looked at to assess progress in the development of informative and effective care plans. Records include 24-hour plans that provide an overview of how the resident spends their day and these included good personal detail. The pre-admission assessment provides indicators of the input and support needed by staff to make sure that care needs are met and care plans are developed. There has been an improvement in the amount of detail being recorded within the care plans. The quality of this information can be further improved to provide staff with more specific detail about care needs. For example, care Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 10 plans to address the risk of skin damage referred to the use of a pressure relieving cushion but did not note the type of cushion; another care plan stated ‘ensure 600-1000mls fluid each day’. There was no information of how this would be monitored. A fall risk assessment indicated a risk and the subsequent plan included the instruction ‘assist when getting in/out of bed’ but did not state how; the personal care plan stated ‘assist with a wash twice a day’ but did not indicate what the resident could do and exactly what assistance was needed. Although care plans were reviewed and evaluated monthly this was not meaningful and did not provided a true indication of how effective the plan had been over the previous month. For example, the review of one mobility care plan only stated ‘no changes’ rather than a more detailed evaluation of how effective the plan had been over the previous month. Daily records are kept as well as a key worker diary. Care plans were not seen for nighttime or for how residents spend their social and leisure time. Records were kept of the input of other healthcare professionals. One communication sheet provided a record that the care plans had been discussed with the relatives and there was evidence of a formal review of the care plans. Risk assessments are being carried out. There appeared to be some duplication of these with particular regard to falls and mobility. This was discussed with the manger and it was suggested that this be reviewed to make sure that staff are not duplicating work. Medication practices were looked at in both houses. Revised policies and procedures have been introduced, dated August/September 2005. These are corporate documents that make clear reference to working within nurses’ professional guidelines and also adhering to guidance from the Royal Pharmaceutical guidance. All the trained staff have annual drug update, which was in early February for this year. There are dedicated medication rooms in both houses. In Park house this room is an internal room and there are problems with temperature control. At the time of the visit the temperature was recorded as 28°C, which is in excess of the 25°C, which is the manufacturers recommended maximum temperature for the storage of medicines. In Oakwood house the medication storage room is rather cramped and access to the sink for hand washing was restricted. Photographs of residents were kept on the medication administration records (MAR) to aid staff in the correct identification of residents prior to giving Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 11 medication. There is a list of signatures of the staff who administer medicines, although some signatures were missing. The manager has recently delegated the overseeing of medication practices, for example returns and disposal to a member of the nursing staff. These systems had been set up but had not been fully implemented. There were some problems with the new arrangements for the return of unused medicines. Only one returns box was seen and there was the equivalent of at least another box of drugs to be returned that were being stored in an open box. There was no written record of these drugs. Handwritten entries were seen on some of the MAR charts that were not signed, dated or countersigned. The controlled drugs were checked in Oakwood house and the quantity was found to be in excess of the number recorded in the book. Records must be accurate. The records of self-medication by one resident were looked at. There was no evidence seen of an assessment of the capacity of the resident to self medicate, although there was clear guidance of procedures to follow within the revised policies and procedures. There was a form signed by the resident dated February 2006 but this was an outdated form and did not follow current procedures. A note was seen signed by the manager instructing staff to observe a particular resident whilst he took his medication. This should not be necessary if staff are following the correct procedure. Oxygen was kept in both medicine rooms. The manager said that this was not prescribed but was for emergency use. There was no evidence to indicate that this had been discussed and agreed with GPs or what policies and procedures staff should follow. A requirement and recommendation has been made. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 and 15. Overall residents exercise choice in their everyday lives and a good varied diet is offered which takes individual choices into account. The manager needs to make sure that this choice is consistent for all residents. EVIDENCE: A number of residents were spoken with and there were some mixed views about the choice that they felt they had in their day-to-day lives. Overall comments were positive ‘it is a good home’; ‘would recommend this home to anyone’; ‘it is pleasant I can more or less do as I like’. However, through conversation with staff and residents it seems that some residents do not feel that they have a choice when it comes to having a bath. One resident said that it was not possible to choose a bath time ‘you have to go when it is your turn’; and although this resident would have preferred her bath in the daytime the night staff bath her around 9pm, she said ‘this is not my choice’. Another resident said that he used to have his bath at 8am, which was his choice. However, this no longer happened and he sometimes had to wait until 10.30am. He had expressed his concerns but in discussion with the senior sister and to the manager there seemed to be some confusion about how this was to be addressed. The manager had made arrangements for his bath to be Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 13 done as he requested but the nurse in charge of the house was not aware of this and it was not documented in his records. There were mixed views about the quality of the food with some residents saying that the food was very good. One resident said that the food was ‘wonderful’ and he had put on a significant amount of weight since admission. However, others were not quite so happy but acknowledged that their comments had been listened to and changes had been made. The lunchtime meal in Park house was quiet and relaxed. It was not clear that all residents were being offered choice and some meals were put down in front of residents without staff saying what it was or offering help. One resident could not cut his own food up and ate his meal with his fingers, no assistance was offered. In another case help was offered to a resident in such a way that she maintained the option to refuse. One resident did not want her main course but no alternative was offered. Recommendations have been made. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Complaints are dealt with appropriately and systems are in place to protect residents from abuse. EVIDENCE: There is a complaints procedure, which is displayed in the home. Monthly returns are sent to head office recording any complaints or compliments received. Recently there have been more compliments than complaints received. The most recent written complaint was made in October 2005 and was concerned with food. Records indicate that this was dealt with appropriately. There was recent correspondence from the complainant acknowledging the action taken in response to the complaint, which included a review of the menus and the inclusion of homemade soups. There is a procedure for staff to follow with regard to adult protection. The manager has attended the trainers’ course on adult protection run by the local authority adult protection unit. A package has been put together to provide training for all staff to start during March. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26. Some practices create the opportunity for cross infection that could place residents at potential risk. EVIDENCE: The home is well maintained and refurbishment is ongoing. During the inspection some control of infection issues were identified and were shared with the manager. One clinical waste bin was not a foot operated pedal bin and did not have a lid. Another foot-operated bin was broken requiring staff to open the bin by hand. Sluice rooms in Park house were very cramped areas with three laundry skips obstructing access to the mechanical sluice washer and top the hand washing facilities. In both sluice rooms the yellow bags were not held within the pedal bins but at the side also obstructing access to the sink. Toilet brushes were dirty and were not being stored correctly in that they were in water. This was discussed with the housekeeper at the visit so that she could take the steps to address the problem. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 16 Colour coded cloths are not used and the housekeeper provided written information from the contractor on the cleaning system being used. One commode was seen with a badly torn lid and both the commode pan and lid were badly stained. A recommendation has been made. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30. The training provided to staff ensures that competent staff meet the needs of the residents. EVIDENCE: National Vocational Qualification (NVQ) in care at level 2 has been achieved by four of the care staff and a further eleven carers are enrolled on the programme. The personal files of two recently recruited members of staff were looked at with particular regard to recruitment procedures. These were found to be satisfactory with all the required checks having been carried out. The staff development officer oversees the training provision and the current focus is on mandatory training for staff. She is highly committed and enthusiastic about her role. Staff spoken with were also enthusiastic about training. One carer said that it had been made clear at interview that she would be expected to undertake training; training was part of her contract of employment and written into her job description. There is an annual training and development plan and the training officer works with the manager in identifying additional training needs. For example, the manager noted that 80 of falls involved residents with Parkinson’s disease. Additional training about Parkinson’s has been provided to staff in an attempt to reduce the number of falls. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 33, 36 and 38. The manager and her staff are committed to running the home in the best interests of the residents. There are some practices that could place the residents at potential risk. EVIDENCE: The manager is currently reviewing the relatives meetings, which have not been well attended over the winter months. She is working to establish the most convenient time to hold the meetings and a social event was planned for the end of March. A system of formal staff supervision has not been properly established and staff do not fully understand what supervision is. Those staff spoken with described individual meetings that they had with the manager when training needs were discussed. These meetings are held every six months and appear Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 19 to be appraisal rather than the ongoing one to one sessions held as part of a formal supervision system. During the tour of Park house some bedroom doors were left open without the appropriate devices in place. The linen cupboards are marked as fire doors and ‘keep locked shut’. Both these cupboards were open and unlocked. Recommendations have been made. Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 2 STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X 2 Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Care plans must set out in detail 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) The manager must ensure that staff follow the home’s policies and procedures. The provider must make sure that practices around the administration, recording, storage and disposal of medicines are safe. The arrangements for the use and administration of oxygen must be agreed. Timescale for action 12/07/06 2. OP9 13(2) 25/05/06 Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 22 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. Refer to Standard OP9 OP14 Good Practice Recommendations A review of the storage facilities for medicines should take place to establish whether more suitable facilities can be provided. The manager should make sure that the wishes of residents are taken into account by staff and that any arrangements about care issues are clearly documented and communicated to all concerned The manager should review the arrangements for the control of infection and make sure that staff are clear about their responsibilities. The manager should make sure that care staff receive formal supervision at least six times a year. Staff should be reminded of their responsibilities with regard to following instructions about the use of fire doors. 3. 4. 5. OP26 OP36 OP38 Sabourn Court Nursing Home DS0000001369.V284550.R01.S.doc Version 5.1 Page 23 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.V284550.R01.S.doc Version 5.1 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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