Inspection on 11/05/07 for Sun Court Nursing Home

This inspection was carried out on 11th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Sun Court Nursing Home 02/02/06

Sun Court Nursing Home 01/06/05

Sun Court Nursing Home 25/01/05

Sun Court Nursing Home 12/10/04

Similar services:

Claremont House

Oak Ridge

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

15 Bramble Close

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

CARE HOMES FOR OLDER PEOPLE Sun Court Nursing Home 1 Morris Street Sheringham Norfolk NR26 8JX Lead Inspector Mrs Maggie Prettyman Unannounced Inspection 11th May 2007 09:00 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 Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sun Court Nursing Home Address 1 Morris Street Sheringham Norfolk NR26 8JX 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) 01263 823295 01263 825382 sun.court@btconnect.com Mrs Janice Laura Leadbeater Mr. Timothy Michael Leadbeater Mrs Valerie Ann Ridley Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (32) of places Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Adults aged 40 years and over Date of last inspection 2nd February 2006 Brief Description of the Service: Sun Court is a detached property situated near the town centre of Sheringham. It provides accommodation on three floors for 29 elderly residents who are in need of nursing care. Most of the rooms are single with en suite accommodation. There is a small paved garden, which is accessible to residents. The Home is well equipped with adaptations and facilities and has good liaison with community health resources. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over the course of 7 hours, during which a detailed tour of the premises was undertaken, people living at the home, visitors and staff were consulted, and a variety of records were examined. Prior to inspection a large number of pre inspection questionnaires were returned from people at the home, their relatives and external health care professionals. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out using information from previous inspections, information from the providers, the residents and their relatives as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the home and current judgements for each outcome group. What the service does well: Sun Court is a home which demonstrates excellent standards in most areas. High quality information about the home is available to people thinking about living there and a detailed assessment of need is undertaken before anyone is admitted. Comprehensive plans of care are kept and regularly reviewed and updated. People’s health care needs are carefully addressed and the system of medication is safe and secure. People living at the home feel that they are treated with respect and dignity by a cheerful, hardworking and carefully vetted and well-trained team of staff. They also feel that their concerns and complaints are listened to and that they are safe and protected from harm. One person said, “I appreciate how they see that both the nursing and homeliness of the place are important. The team here demonstrate excellence, flexibility and true professionalism.” Despite its physical limitations, the home is spotlessly clean and high standards of infection control are in place. The management team at the home are experienced, trained and mature. They lead by example, are innovative, and ensure that high standards are maintained in all aspects of the home. A system of quality assurance is in place Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 6 and results from audits and satisfaction surveys are used to inform and support the excellent standards of practice at the home. One relative wrote, “They treat my mother as an individual and they take an interest in her family. Her hygiene and comfort are carefully managed. Staff are friendly and special days are always celebrated.” What has improved since the last inspection? During the inspection it was clear that this is a home which constantly strives to improve and develop its service to the people who live there. Many aspects of the home have improved since the last inspection, but of particular note are: • • The Service User Guide has been updated and contains detailed and current information The home is using the Gold Standard Framework and the Liverpool Care pathway to ensure that end of life care meets the needs and wishes of people and their families in all respects Fire safety on the upper floor has been reviewed and improved Antibacterial hand gels are strategically available throughout the home Levels of NVQ training amongst staff have increased A Satisfaction survey has been undertaken by an independent body and action taken as a result • • • • What they could do better: Sun Court is an excellent home which operates to very high standards. During the inspection a few areas of improvement were identified; • Care needs to be taken to ensure that all records made about people are kept in their individual files so that they can always know what is being written about them and so that all information is available for review. Some personal toiletries were not labelled and dividers would improve storage in bathroom cabinets in shared rooms A sanitising product kept in bathrooms should be stored according to a risk-assessed protocol. • • Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 People who use the service experience excellent Quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who are thinking about coming to live at the home and their families have the information needed to choose a home, which will meet their needs. A full and detailed needs assessment is undertaken before anyone comes to live at the home. EVIDENCE: Examination of the home’s Service User Guide demonstrated that it is factually correct, informative and accessible. This guide has been updated to reflect current charges and facilities at the home. A person living at the home who had recently come to stay commented that the information was useful and accurately reflects the lifestyle and care provided. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 10 Examination of records held for each person living at the home demonstrated that extremely detailed and professional ‘needs assessments’ are conducted by the home prior to people coming to live there. People living at the home confirmed that the home is able to meet their needs and that they were more than happy with the admissions process, which they found supportive and informative. The homes management team confirmed that they do not provide intermediate care. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11 People who live at the home experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy underpin all elements of practice. EVIDENCE: Examination of people’s individual care plans demonstrated that they are comprehensive, up to date and well maintained. Risk assessments are in place and notes carefully separate different elements of care to ensure that they can be effectively reviewed. The home plans to implement monthly reviews in partnership with people to quality audit their satisfaction with the care that they receive. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 12 Detailed health care notes and assessments were in place in all individual records examined. Pressure areas are risk assessed and managed. Records demonstrated that all aspects of individual health care are promoted. People interviewed spoke highly of the support they receive. Three people described how well the home had helped them to recover from serious illness and to continue to make positive progress. People are supported to access all forms of healthcare support from external providers. The home itself employs a physiotherapist to offer this specialist support at no extra charge. Examination of the system of medicine administration demonstrated that it is well managed and that records are meticulously kept and audited. Evidence of regular training and support for staff administering medicines was seen. People’s medication is regularly reviewed in conjunction with the visiting GP and the local pharmacist. Feedback from pre-inspection questionnaires, discussions with people living at the home and their visitors as well as observation of staff conduct during the inspection demonstrated that people are treated with the utmost respect and regard. People confirmed that they have access to private telephones, receive their letters unopened, that their clothes and possessions are carefully kept and that they are addressed in the form that they wish. During the tour of the building some personal items such as shampoo were occasionally found not to be individually labelled and in shared rooms the bathroom locker is not divided. A recommendation has been made in this respect. The home has made significant progress in the past year with its end of life system of care. The existing high standards have been further enhanced with the use of the Gold Standard Framework of life care and the Liverpool Care Pathway. The home has been innovative in the production of excellent supportive literature for relatives and bereavement counselling for staff who work at the home. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 People who live at the home experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are able to make choices about their lifestyle and the social and cultural activities of the home reflect their wishes and expectations. EVIDENCE: An activities board in the hallway shows events planned for the week. The home acknowledged that people might be better informed by being given these details individually and plan to introduce this in the near future. A range of group and individual activities take place. Musicians and a hand masseur visit people who are bed fast if they wish. People commented that entertainment provided had been of a good standard and enjoyable. A group discussion takes place once a week. People were supported to vote in recent elections and had visits from local candidates. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 14 People living at the home and their visitors confirmed that they are given every support to maintain their friendship and social networks. Visitors confirmed that they are warmly welcomed and offered refreshments at no charge. They also confirmed that they could come and go as they wish. The home has recently produced some excellent thought provoking documentation on maintaining personal relationships whilst at the home. People living at the home confirmed that they feel in control of their lives and that they are consulted about their care and their lifestyle. Information on advocacy is freely available. The home arranged for the pre-inspection survey to be conducted by an independent organisation. Pre-inspection questionnaires and feedback given by people on the day confirmed that food provided is of a high quality and that people have choice about what they eat. Menus demonstrated that the food is wholesome and nutritious. People commented that their food is well presented and that pureed foods are presented separately on the plate. Records demonstrated that nutritional assessment takes place and that special diets are provided. Lists of preference were seen in the kitchen and were carried by staff serving teas and coffees. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 People living at the home experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at the home are able to express their concerns and have an effective complaints procedure. Staff training ensures that they are protected from abuse. EVIDENCE: During the inspection copies of the homes complaints policy were seen in each persons room as well as at other strategic locations around the home. People said that they can comment about the service provided and are happy to do so. A register of minor complaints is kept. The home plans to develop further auditing of comments, suggestions and compliments in the future. Training records and policies and information given throughout the home demonstrated a strong awareness of and robust approach to adult protection principles and practice. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20 and 26 People living at the home experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The homes’ design and layout enables people who live there to do so safely and comfortably. Standards of cleanliness and hygiene are exemplary. EVIDENCE: A tour of the premises demonstrated that the home is safe and well maintained. All areas of the home are accessible and individual and collective needs are met in a comfortable and homely way. There is a programme of maintenance and a small, but tidy and accessible garden provides an outdoor sitting area. Records demonstrated that the building meets environmental and fire regulations. The home has further improved its fire safety arrangements on the upper floor in the past year. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 17 The home has two small communal areas which double as dining rooms. The home is smoke free throughout. Lighting and furnishing in these areas is domestic and comfortable. A tour of the premises demonstrated that the home is spotlessly clean and hygienic throughout. A hard working and cheerful team of domestic staff were observed performing their tasks professionally and efficiently. Cleaning products are COSHH assessed, correctly stored and available in sufficient quantities. The laundry is small, but with good quality equipment. Clothes were seen to be properly sorted and returned to their owners swiftly and efficiently. Notices about infection control were clearly displayed in staff areas. The home has recently installed antibacterial gel dispensers throughout. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 People who live at the home experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are carefully vetted, trained and skilled, and are in sufficient numbers to support the people who live there. EVIDENCE: Examination of rotas as well as observation of numbers of staff on duty on the day of inspection demonstrated that the home is well staffed. Computer records and analysis of staff numbers and monitoring of hours worked demonstrated that staff hours are well managed and that levels of cover are the same at weekends as during the week. Staff training records as well as statistical computer analysis demonstrated that the home exceeds the minimum NVQ levels required by the standards. Staff records also demonstrated a detailed and professional induction programme that is in line with TOPSS standards. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 19 Examination of staff records demonstrated that staff are carefully and thoroughly risk assessed and vetted prior to working at the home. Contracts of employment were seen in all files inspected. Clarity is given with regard to working hours and terms and conditions of service and payment. Staff records demonstrated that they are properly inducted and that mandatory training is in place and kept up to date. The home produces a detailed annual training plan, a copy of which was given to the inspector. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33 35, 37 and 38 People who live at the home experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The home has effective quality assurance systems which are developed by a qualified and competent management team. EVIDENCE: The home is run by a management team including the homes owners. All members of this team are qualified, experienced, mature and competent people who throughout the inspection demonstrated commitment to providing quality flexible services to the people who live there. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 21 The homes ethos is one of a family run environment providing professional care in a supportive and compassionate way. The management team give clear and consistent direction by providing clear and concise policies and procedures as well as a system of supervision and support. People who live at the home confirmed that the management is open and accessible. An example of innovative development was seen in the production of a recent policy for relationships at the home. A range of quality assurance systems and procedures are in place and in development. Views of people living in the home were seen incorporated into the policies and procedures of the home. A detailed satisfaction survey has been recently conducted, and action has been taken to address issues raised by people who live at the home and their relatives. It is of particular note that the home uses an independent organisation to conduct their own survey and to support people returning the Commissions pre-inspection questionnaires, resulting in an extremely high level of feedback which assisted the inspection at all levels. Records of small amounts of money and personal valuables held by the home on behalf of residents were inspected and found to be up to date and correct in all respects. Clear information about safe keeping of valuables is given to people in the Service User Guide. Inspection of records held by the home demonstrated that they are up to date, factual and securely kept. It was noted that a handover sheet was used which contained individual detail that needed duplication to the care plan. Whilst most notes were correctly transferred not all social care notes had been. This means that people do not have access to these notes in their care plans which they have access to in their own rooms. As such their access rights under the data protection act could be compromised and not all information may be available for review. A recommendation has been made to this respect. The tour of the building as well as inspection of records and discussions with staff and people living at the home demonstrated that safe working practices are employed by the home. Compliance records were seen, detailed risk assessments are undertaken and a comprehensive record and audit of accidents are maintained and used to reduce risk. During the tour of the building a sanitising product was found in various locations that were not secure. A recommendation has been made in this respect. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 22 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 3 X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 4 X 3 4 Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 23 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. 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. 1 2 3 Refer to Standard OP10 OP38 OP37 Good Practice Recommendations All personal toiletries should b e individually labelled, and consideration given to dividing bathroom cabinets in shared rooms. A risk assessment for location and storage of the sanitising product used in bathrooms should be undertaken. Handover notes should not contain records, which are not fully transferred to people’s individual files. People should have access to all records that are made about them, and all information should be available for review. Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Sun Court Nursing Home DS0000015687.V339581.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!