Inspection on 14/02/06 for Sibbertoft Manor Nursing Home

This inspection was carried out on 14th February 2006.

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

Sibbertoft Manor Nursing Home 06/12/06

Sibbertoft Manor Nursing Home 22/07/05

Sibbertoft Manor Nursing Home 30/11/04

Sibbertoft Manor Nursing Home 01/09/04

Sibbertoft Manor Nursing Home 17/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Sibbertoft Manor Nursing Home Church Street Sibbertoft Market Harborough Leicestershire LE16 9UA Lead Inspector Mrs C A Burgess Unannounced Inspection 09:30 14 February 2006 th 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 Sibbertoft Manor Nursing Home DS0000012641.V279106.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. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Sibbertoft Manor Nursing Home Address Church Street Sibbertoft Market Harborough Leicestershire LE16 9UA 01858 881304 01858 881488 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) Pretty 333 Limited Mrs Patricia Margaret Bevin Care Home 28 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (28), of places Terminally ill over 65 years of age (28) Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one falling within the categories of OP or TI(E) may be admitted into the home for nursing care where there are 28 persons in the categories OP or TI(E) already accommodated within the home with nursing needs No one falling within the category of DE(E) may be admitted into the home for personal care where there are 15 service users who fall within the category of DE(E) already accommodated within the home No one falling within any category prescribed by the Care Standards Act 2000 and its Regulations can be accommodated in the home where there are already 28 service users accommodated within the home 22nd July 2005 2. 3. Date of last inspection Brief Description of the Service: Sibbertoft Manor nursing & residential care home can accommodate residents over 65 years (who may have dementia or a terminal illness) within a safe environment. Trained nurses and care assistants staff the home, with a trained nurse on duty at all times. The home is situated in the pleasant village of Sibbertoft, on the boarders of Leicestershire and Northamptonshire and is set within extensive, safe enclosed gardens and overlooks open countryside. All residents’ spacious rooms have en-suite facilities and there are additional toilets and assisted bathing facilities. There are a number of pleasant, separate sitting rooms, including a quiet room, and dining areas throughout the building. All areas of the home and garden, accessible to the residents, are ‘wheelchair friendly’, and there is a passenger lift to the first floor. The home is clean and well maintained throughout and has satellite TV. All meals are freshly prepared on site. The home has a minibus and there are car-parking facilities next to the home. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over four and half hours. An opportunity was taken to look around the home, view records, policies and care plans and to talk to residents and their relatives/visitors. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they receive through a review of their records, discussion with their relatives (where available), and observation of care practices. Many of the residents were seen during the inspection. Four of the residents and a relative spoken with gave the Inspector their impressions of the home. What the service does well: Sibbertoft Manor provides safe and supportive care for residents within the nominated categories. The home has adaptations to assist with care and to help residents achieve their optimum independence, and exercise personal choice within their capacity to do so. The standard of care is high, and the home is clean and well maintained and has a cheerful and busy atmosphere. The home has been awarded with the Investors in People Award and has a 4 Rose rating from the Northampton County Council Accreditation Officer, 2004 - 2005. The home is well managed by the Registered Manager. Care planning and risk assessments ensure that the residents’ health and welfare needs are met. Staff relationships with residents and their relatives are excellent, demonstrating care, patience and understanding of each resident’s individual care needs. Fresh food is purchased and prepared on site. Special requirements are catered for. Residents spoken with said the food was ‘always very good’. Visitors can eat with their relatives free of charge. A visitor said that their relative was very well cared for; that the standard of care and cleanliness in the home was high; that the food was very good and well presented, and visitors were made welcome at any time. Staff treat all of the residents with a high degree of dignity and respect and the home provides a very high standard of care for the residents for which all of the staff are to be commended. Sibbertoft Manor Nursing Home DS0000012641.V279106.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. Sibbertoft Manor Nursing Home DS0000012641.V279106.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 Sibbertoft Manor Nursing Home DS0000012641.V279106.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. The admission process is well managed and residents receive a satisfactory assessment, thereby ensuring that their health and welfare needs are met. EVIDENCE: In the residents’ files, reviewed during the inspection, the pre-assessment process, completed by either the Registered Manager, who is an experienced and well qualified nurses, was reflective of the health, welfare and social needs of prospective residents and informed subsequent care plans. The home does not provide intermediate care. Standards 1, 2, 3 & 4 were inspected in July 2005 and found to be met. Sibbertoft Manor Nursing Home DS0000012641.V279106.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, 9 & 10. Residents are well looked after in respect of their health and personal care. EVIDENCE: Individual care plans were detailed and comprehensive to ensure that the residents’ needs were fully met. On 13/02/06 most of the nursing staff undertook medication update training by the Primary Care Training Group. Medication administration is managed effectively within the home’s medication policy and procedural guidelines by the Registered Nurses to ensure the safe and timely delivery of residents’ prescribed medicines. Observation during the inspection showed that staff have a good awareness of how to protect residents privacy and dignity. Staff were seen to be kind and patient and treat the residents in a respectful, friendly and supportive manner. Four residents spoken with said that staff were respectful, patient, caring and kind and made relatives feel welcome. Standards 7, 8 & 9 were inspected in July 2005 and standards 7 & 8 were found to be met. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 10 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): 13, 14 & 15 partially. The staff work hard to ensure that residents experience a safe, homely life style. EVIDENCE: The home has a routine, which includes specific meal times and activity timetables although these are flexible to meet the individual requirements of the residents. There is an Activities Organiser who works four days a week and arranges a weekly programme of activities and outings suited to residents’ particular needs. There is also an ‘Activities Support Group’ organised by a resident who arranges weekly videos to be shown. A church service is held monthly at the home, which is also attended by a small number of villagers. A relative said that visitors could visit at any could visit at any time. There are celebrations throughout the year at Christmas and Easter etc; including a summer fête; this enables residents and their relatives to enjoy seasonal and community activities. Birthdays and special days are celebrated. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 11 Meals are prepared on site from fresh produce in a clean, modern industrial kitchen. The dining areas were clean and table attractively laid for lunch. A cooked breakfast is available daily, there are choices at all meal times and individual preferences are noted. Wine is provided at no extra cost. Special diets such as diabetic, soft or puréed diets can be catered to ensure that residents’ personal and medical needs are met. Residents said that the meals were very good. One resident said that staff would provide drinks and snacks during the night if he could not sleep. Standards 12 & 15 (partially) were inspected in July 2005 and were found to be met. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 12 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): 17 & 18. Arrangements for receiving and responding to complaints are sound resulting in satisfactory protection of residents’ rights. EVIDENCE: The home’s complaints and adult protection process reflects the government’s adult protection and local guidelines, but may require updating to fully encompass current Department of Health guidance. This was discussed with the Registered Manager who agreed to check with the local authority and obtain further information. Staff are aware of these procedures and receive relevant training. Complaints and concerns made to the home are dealt with appropriately. The home has not received any complaints since the previous inspection. The CSCI have not received any complaints relating to the home. Standards 16 & 18 (partially) were inspected in July 2005 and were found to be met. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 & 26. A comfortable, clean and safe standard of accommodation is provided for the residents. EVIDENCE: The home is safe and well maintained with adaptations to suit residents’ specific needs. It is decorated and furnished to a high standard which creates a comfortable and homely environment, and there is a system of maintenance and refurbishment. Resident’ rooms were clean, spacious and well decorated and have en-suite facilities. Residents are able to bring items of their own furniture and possessions with them to personalise their rooms. Many rooms were personalised with photographs, paintings, ornaments and furniture. All rooms have en-suite facilities and there are additional toilet, bathing and assisted bathing facilities. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 14 The home is responsive to the specific requirements of individual residents where additional space and privacy is required. There is some provision for married couples to have shared accommodation with a bedroom, en-suite shower room and separate sitting room. On the day of inspection all areas of the home were clean and maintained to a high standard, which was commented upon by the residents and relative spoken with. The standard of accommodation and cleanliness provided for the residents, in both communal areas and residents’ rooms, is of a high standard and is commended. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30. Staff at the home are sufficient in numbers to meet the residents’ needs. EVIDENCE: Staffing levels, at the point of inspection were satisfactory and in accordance with that indicated by the Department of Health Residential Forum Guidelines, and were sufficient to meet the resident’ needs. The home employs a mixed staff group consisting of Registered Nurses and care staff, supported by domestic, catering and maintenance personnel. There are always qualified nurses on duty, day and night, to ensure that the residents’ nursing needs are met. The Registered Manager said that staff retention was high and that some staff had worked at the home for many years. There is a comprehensive induction booklet for new staff to complete. Resent staff training/updates organised by the home include fire training, nutrition, swallowing & feeding problems, communication, moving & handling, basic food hygiene and dementia care. The Registered Manager stated that eleven care staff have National Vocational Qualifications (NVQ) in Care, Level 2/3, a further 5 care staff were undertaking NVQ’s and a number of staff had expressed an interest in studying for an NVQ in Care - which the home would support. Residents and a relative said that the staff were supportive and caring, and that there are sufficient staff on duty to meet the needs of the residents. Standards 27 & 29 were inspected in July 2005 and were found to be met. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 & 38. The Registered Manager is a trained nurse, and is knowledgeable, experienced and professional, and effectively supervises staff and manages the home to protect the rights and needs of the residents. EVIDENCE: The Registered Manager is a Registered Nurse and has many years of experience and has recently successfully completed the Registered Managers’ Award. She should be commended for her professionalism and commitment to maintaining and improving the high standard of care for the residents. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 17 There is an ethos of openness in the home; staff are friendly, helpful and very caring towards the residents, their relatives and each other. Health & Safety Policy and Procedures, such as regular recorded fire alarm tests and water temperature tests are completed, to assure the health and safety of the residents and staff. Standards 36 & 38 (partially) were inspected in July 2005 and were found to be met. Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 4 4 4 X 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X X X 3 X X 3 Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Sibbertoft Manor Nursing Home DS0000012641.V279106.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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