CARE HOMES FOR OLDER PEOPLE
Sibbertoft Manor Nursing Home Church Street Sibbertoft Market Harborough LE16 9UA Lead Inspector
Sarah Smart Unannounced 22 July 2005 13.00
nd 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. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Sibbertoft Manor Nursing Home Address Church Street Sibbertoft Market Harborough Leicestershire LE16 9UA 01585 881304 01585 881488 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) Pretty 333 Limited Mrs Patricia Margaret Bevin Care Home with Nursing 28 Category(ies) of OP Old Age (28) registration, with number TI(E) Terminally Ill - Over 65 Years (28) of places DE(E) Dementia - Over 65 Years (15) Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 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. 2. 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. 3. 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. Date of last inspection 30th November 2005 Brief Description of the Service: Sibbertoft Manor care home with nursing, has extensive grounds and is located in a large country house in a small village. The home has a selection of shared and single bedrooms, some of which are very generously sized. The home is laid out on two floors with a passenger lift, and has a variety of communal areas, which are decorated and furnished to a high standard. the home has a minibus. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken between the hours of 1.30pm and 4pm. Preparation for the inspection included, and took approximately 1.5hours. The primary method of inspection used was ‘case tracking’. This involves selecting a number of service users and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The following areas were covered during the inspection: case tracking, statement of purpose, medication, staff rota, staff files, accident records, previous requirements made, and staff and service user interviews. service users were case tracked. One staff member, plus the manager, were interviewed at length, and several others briefly, whilst two service users were spoken to in detail. What the service does well:
The statement of purpose and contracts of residency gave the reader adequate information. Pre-admission assessments were recorded, and contained satisfactory information. Service users spoken to stated that their needs are met, and that the staff are always pleasant towards them. They added that they are always afforded choices regarding when to rise and retire, bathing, and meals. They said that the food was very good. Care plans evidenced the next of kin involvement in the writing, and were reviewed. Healthcare assessments were generally in place. The home have not received any complaints since the last inspection, and staff spoken to demonstrated a good knowledge of the complaints procedure and the abuse policy. The environment of the home is maintained to a very high standard. A new extension recently completed offers larger than average rooms, with sitting areas in addition to the bed area. All of the rooms have ensuite facilities, some have shower rooms. The home was clean and tidy, and fresh flowers decorated the communal areas.
Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 6 Staffing levels were consistent, and adequate to meet the needs of the service users. Staff files demonstrated robust recruitment processes within the home, and contained recorded staff supervision and appraisal. 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 C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.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 Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.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) 1,2,3,4 Information is available to adequately inform service users about the home, and staff about service users needs. EVIDENCE: The statement of purpose contained all of the information outlined in schedule 1. The service users contracts also fully informed the reader of the responsibilities and expectations of both the home and the service user. Assessments were recorded on the service users files which were carried out prior to their admission. Such assessments contained a satisfactory amount of information, ensuring that the home are able to meet the service users needs. From observation carried out, and discussions with service users and staff, it was apparent that the service users current care needs are met. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 With the exception of medication, the healthcare needs of service users are met. EVIDENCE: Care plans were seen to be in place covering all of the service users needs identified. In some instances slightly more information may be useful in the instructions to staff, to ensure consistency in the provision of care. The plans were reviewed at least two monthly, or as the needs changed. The care plans had been signed by the service users next of kin. Healthcare assessments were recorded appropriately, although the service user case tracked may benefit from a continence assessment. A sample of medication was viewed, and indicated that storage and recording was satisfactory. Evidence was found that at least one staff member dispenses medication into labelled pots in batches, before administering it to the service users. This is dangerous practice, and is not in line with Nursing and Midwifery Council guidelines, as each medicine must be dispensed, administered, and signed as given, before moving to the next service user. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 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 standard(s) 12 and15 partially Service users dietary and social needs are met. EVIDENCE: Service users spoken to by the inspector stated that they have the opportunity to go out regularly, visiting local towns and attractions. The service users stated that the food provided in the home is nice, and they are offered a choice. They also stated that they are able to choose their rising and retiring times, and when they would like to bathe etc. These were recorded in the service users assessment. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 11 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) 16 and 18 partially Service users are adequately protected. EVIDENCE: The manager stated that the home have not received any complaints since the last inspection. Staff spoken to demonstrated a good knowledge of the action to be taken in the event of a complaint being made to them. The staff member also demonstrated an acceptable knowledge of the procedure to be followed in the event of an allegation of abuse. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 12 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) 19,20,23,24,26 The premises are maintained to a high standard, and are fit for purpose. EVIDENCE: The home is maintained to a high standard, both internally and externally. The home have recently had a large extension completed, providing additional accommodation to service users. This was the area of the home viewed. All of the service users bedrooms seen were furnished to a high standard, many with service users own possessions around them. The bedrooms were larger than the required 12 square metres, and in many cases provided a seating area, in addition to the area of the bed. Al of the rooms had ensuite facilities, some of which had walk in showers fitted. There appeared to be adequate provision of grab rails and equipment etc. The manager stated that an additional hoist had been purchased for use in the new bedrooms. Two lounges and a dining room were viewed. These were spacious areas, with a selection of appropriate seating. Fresh flowers were also arranged in the communal areas.
Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 13 In some areas of the home keys to a service users bedroom door were hung on a hook outside the door. This was discussed at length with the manager, who agreed to remove them, therefore a requirement has not been made. All areas of the home viewed were clean and tidy. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 14 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) 27,29 Suitable staff are employed in sufficient numbers to meet the needs of the service users. EVIDENCE: The staff rota demonstrated that in addition to the manager, who is a registered nurse, the home is staffed by one nurse and a minimum of four carers during the morning, one nurse and four carers during the afternoon, and one nurse and two carers at night. None of the staff were working an excessive number of hours, and the staffing levels were appropriate to meet the needs of the current service users. A sample of staff files indicted that all of the required information is held. The manager demonstrated a good understanding of the requirements and importance of completed staff files. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 15 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) 36, 38 partially The management of the home is satisfactory. EVIDENCE: Records were available of supervision and appraisal for all staff members whose files were viewed. Accident records were viewed, and observed for trends. During the month of May 11 out of 14 accidents recorded were not witnessed by staff, and 8 out of 10 in June. The manager stated that this is due to the type of needs of the service users accommodated in the home, however it is recommended that the manager continues to monitor this. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 16 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 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 4 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x 3 x 3 Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 17 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 9 Regulation 13(2) Requirement Administration of medication must be in line with NMC guidelines. Timescale for action By 25.8.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 7 8 38 Good Practice Recommendations Care plans should contain further specific information instructing staff. Continence assessments should be introduced. The manager should monitor the accident records for signs of trends occuring. Sibbertoft Manor Nursing Home C51 C08 S12641 Sibbertoft Manor V240423 220705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 1st Floor, Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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