Inspection on 16/08/05 for Sambrook Care Limited

This inspection was carried out on 16th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sambrook Care Limited 09/01/08

Sambrook Care Limited 14/11/06

Sambrook Care Limited 02/03/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Sambrook Care Limited Sambrook House Sambrook Newport TF10 8AP Lead Inspector Rosalind Dennis Unannounced 16 August 2005 10.00 th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Sambrook Care Limited Address Sambrook House, Sambrook, Newport, TF10 8AL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01952 550210 01952 550690 www.sambrookhouse.co.uk Sambrook Care Limited Jennifer Bethell Older People 28 Category(ies) of Old Age (28) registration, with number of places Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 29/11/2004 Brief Description of the Service: Sambrook House is situated in the small village of Sambrook, on the outskirts of the Shropshire Town of Newport, and is registered to provide accommodation and personal care for twenty-eight older people. The home has been converted from a large country house and there are double and single rooms some of which have en-suite toilet facilities. The accommodation is on two floors, the upper being accessed by stairs or via a shaft lift. On the ground floor are pleasant lounges and dining areas, which are well decorated and comfortably furnished, the well-maintained grounds are also available for residents’ use. Care is planned in consultation with individual residents and is reviewed regularly. The home also offers a variety of in-house activities, which are optional, outings and special events are arranged throughout the year. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted for approximately 6 hours. The inspection involved observing activity within the home, a tour of the premises, looking at care records and observation of documents. The inspector spoke with residents, one visitor and staff that work at the home. Residents appeared happy, content and well cared for and all spoke positively regarding the home and care received. The manager and staff on duty were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: Shortfalls in this home are few. As a result of this inspection the registered person is required to ensure that staff are aware that the wedging open of doors is an unacceptable practice and Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 6 must cease. Bed rail risk assessments must also be implemented for residents that are assessed as needing bed rails. One requirement outstanding from June 2004 is for the home to provide a central heating system that is controlled in all resident’s bedrooms and the registered person is required to meet this requirement by 1/02/06. Five bedrooms do not have heating systems that can be individually controlled by the resident. The registered person is required to continue consulting with individual residents to ensure that the heating available meets the need of the individual until the current heating system is reviewed. 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. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4, 5 and 6. Staff individually and collectively have the skills and experience to deliver the care required by residents. The home has an admission procedure that is effective in ensuring that individuals moving into Sambrook House know that the home will meet their needs. EVIDENCE: Through discussion with residents, observation of care plans and staff training certificates and observing staff working with residents, the home demonstrates that it meets the needs of the current residents. Observation of one resident’s file recently admitted to the home confirmed that the assessment and subsequent care plans drawn up meet the standard. The resident had been assessed during a visit to the home prior to making the decision to stay. A structured pre-admission assessment checklist may further enhance the admission procedure and this was discussed with the manager for consideration. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 9 Observation of residents files demonstrate that residents have a contract with the home, these documents have recently been revised to take into account the change of ownership and are clear and easy to read. The home has a comprehensive Statement of Purpose, the manager and provider confirmed that the service user guide is currently in the process of being reviewed, therefore this standard was not fully assessed. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 11 There is a clear and consistent care planning system in place that provides staff with the information they require to satisfactorily meet resident’s needs. The health care needs of residents are met by staff in the home and by healthcare professionals that visit the home on a regular basis. EVIDENCE: Within three care files inspected there was good evidence of health care for residents being maintained. Care plans had been reviewed on a monthly basis and any action taken as a result of this review was also documented. Reports written by staff on a daily basis corresponded to the care plan. Risk assessments are conducted for pressure sore risk and moving and handling and reviewed regularly. A social care plan/life story was present on each resident’s file seen enabling staff to deliver care in a personalised way. The manager confirmed that residents may be registered with a GP of their choice although most residents choose to be registered with a local practice and GPs visit from this practice on a weekly basis. One GP visited during the inspection and a relative that was visiting spoke of the benefits of this service. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 11 Observation of “food charts” shows that the home maintains records of dietary intake for residents that are considered to be nutritionally at risk. The residents weight charts show that most residents are weighed monthly however gaps in one record were noted and the manager was advised to record the reason for not weighing individual residents. One resident that had bedrails fitted to her bed had been assessed as needing them via the District Nurse and it was discussed with the manager that the home is also required to complete a risk assessment and keep this assessment under review. It was observed that night staff currently write in care records in red pen and the manager was advised to ensure that written entries in care files are made in an appropriate colour such as black. The home has addressed the sensitive matter of what to do in the event of a resident’s death and details were recorded on resident’s records. Discussion with the manager demonstrated that sensitive and appropriate review would be made if the home were unable to meet the deteriorating condition of a resident. The inspector spoke at length with eleven residents all of whom considered that they have everything they need and commented positively about the care they receive. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14 and 15. The staff work closely with residents to establish individual preferences and promote choice. The home provides social and recreational activities that provide variation and interest for people living in the home. The meals in this home are good offering choice, variety and catering for different nutritional needs. EVIDENCE: Observation of the activities board in the reception area and residents care files demonstrates that the home provides a range of activities for residents to take part in if they choose. Some residents enjoyed a bingo session during the afternoon of the inspection, other residents reported that they had chosen not to take part preferring instead to sit quietly and that staff respected this. All residents confirmed that the home offers a sufficient range of appropriate activities. Observations at mealtimes showed that the routine is based around individual preferences with some residents choosing to eat their meals in their own rooms. The meal served appeared appetising, all residents confirmed that a Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 13 choice is offered and expressed their satisfaction with the meals provided. Observation of a selection of menus demonstrate that nutritional needs are met. Staff were observed to be attentive at meals, offering assistance as and when needed by residents. Close inspection of the main kitchen was not made, however it was apparent that parts of the kitchen required refurbishment and the manager confirmed that this is in hand. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Arrangements within the home for the protection of residents from abuse are satisfactory. EVIDENCE: The home has a policy in place with regard to the protection of adults from abuse and a copy of the local area adult protection procedure was observed to be readily available within the home. Training in adult protection/abuse awareness is provided for staff as part of induction and an ongoing basis. Three members of staff confirmed that they would report any allegation or suspicion of abuse immediately and through discussion with the inspector demonstrated their awareness of the adult protection policy including whistle blowing. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23, 24, 25 and 26. The standard of the environment is good providing residents with an attractive, clean and homely place to live. EVIDENCE: The home was observed to be clean, well maintained with a good standard of décor and furnishings. Individual bedrooms were personalised with resident’s possessions and furniture. Some resident’s rooms have recently been redecorated and the manager confirmed that residents were involved in choosing the décor. Residents spoke of their satisfaction with their bedrooms and with the cleanliness of the home. Heating within five bedrooms cannot be adjusted on an individual basis and the provider acknowledged this outstanding requirement. Although the current residents appear satisfied with the heating in their bedrooms, individual consultation must continue to take place until the central heating system is replaced. The hot water temperature taken from a wash hand basin was Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 16 within the required limits. Records to confirm that regular checks are made on hot water temperatures were not checked at this inspection. Systems were observed to be in place to control the spread of infection and staff were observed utilizing appropriate protective clothing and hand washing facilities. Infection control training is included as part of staff induction and on an ongoing basis. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The home has a stable group of appropriately skilled staff, employed in sufficient numbers to meet the needs of each resident. The home has a robust recruitment procedure that protects residents from the employment of inappropriate staff. EVIDENCE: Staffing levels remain at 3 care staff during the day and evening and 2 care staff at night. The manager is supernumerary and provides on call cover. Residents reported that the level and competence of staff is sufficient to meet their needs and staff also view the levels as being adequate. Staffing levels appear sufficient for the current client group and staff were observed to respond promptly to residents requests and to call buzzers. Staff carried out their duties in a sensitive and professional manner. A staff member recently employed by the home spoke positively of her induction. Observation of staff files confirms induction training meets the required level. Staff are supported in achieving NVQ Level 2 and some staff are in the process of studying for or have attained Level3. Staff files were well maintained and all elements required by Schedule 2 of the Care Homes regulations were found on the files of two staff recently recruited by the home. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34 35, 36, 37 and 38. There are clear lines of accountability within the management structure and the management approach creates an open and positive atmosphere from which residents and staff benefit. The health, safety and welfare of residents are promoted by a well-maintained environment. EVIDENCE: Residents and/or their representatives maintain responsibility for their own financial affairs. Residents can request for the home to retain small amounts of cash for safekeeping and records held by the home were observed to be accurate and well maintained. Financial records that have recently been examined by CSCI demonstrate that the home is financially viable. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 19 Evidence was available to demonstrate that formal supervision and appraisals are undertaken. The supervision arrangements consist of twice yearly appraisals supplemented by regular supervision of practice. To further enhance the current supervision arrangements the manager is advised to consider incorporating a one to one reflective feedback session after each observation of practice. Discussion with three members of staff confirmed that a good supportive network is in place. Staff have access to a range of policies and procedures that are kept under review. Observation of staff files and training documents confirm that staff receive training in all safe working practice topics. All records pertaining to the maintenance and servicing of equipment were observed to be up to date. Accidents are recorded appropriately and CSCI notified promptly when necessary. General risk assessments for the home were not assessed at this inspection. The set of bed rails that were in use were fitted correctly and the manager confirmed that these had been provided via the District Nurse. The home is advised to ascertain who has responsibility for the general maintenance of bed rails whilst on loan to the home. It is also strongly recommended that regular checks be made on any bed rails in use to ensure that correct fitting is consistently maintained. The local fire officer conducted an inspection of the premises in June 2005 and had identified that fire safety arrangements within the home appeared satisfactory apart from the wedging open of two bedroom doors. During this inspection one bedroom door was found wedged open which appeared to be for cleaning purposes. The manager confirmed her awareness that door wedges must not be used and confirmed that all doors are kept shut at night. The registered person must ensure that all staff are aware that the wedging open of doors is an unacceptable practice and must cease. Throughout the inspection residents were forthcoming in their comments and spoke positively about the staff team, management structure and the home in general. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x 3 x 3 3 3 3 2 Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 21 No 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 OP 8 Regulation 13(4) Requirement The registered person must ensure that risk assessments are completed for residents assessed as needing bed rails. The home must provide a central heating system that is controlled in residents bedrooms, and until this can be achieved individual consultation must continue to take place to ensure the heating available meets the needs of the individual. (Previous timescale of 30/06/04 not met). The registered person must ensure that all staff are aware that the wedging open of doors is an unacceptable practice and must cease. Timescale for action 16/09/05 2. OP 25 23(2)(p) 1/02/06 3. OP 38 23(4)(e) 1/09/05 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. Refer to Standard OP 3 OP 8 Good Practice Recommendations The home is advised to consider implementing a structured pre-admission assessment checklist. It is recommended that if it is not appropriate to weigh a E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 22 Sambrook Care Limited 3. OP 36 4. 5. OP 38 OP 38 resident then the reason why the resident has not been weighed is recorded. To further enhance the current supervision arrangements the manager is advised to consider incorporating a one to one reflective feedback session after each observation of practice. The home is advised to ascertain who has responsibility for the general maintenance of bed rails whilst on loan to the home. It is strongly recommended that regular checks are made on any bed rails to ensure that correct fitting is consistently maintained. Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 Page 23 Commission for Social Care Inspection 2nd Floor, St Davids Court Union Street Wolverhampton WV1 3JE 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 Sambrook Care Limited E56 000063772 Sambrook Care Limited v245588 UI 160805 Stage 4 vers 2.doc Version 1.40 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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