Care Home: Sabourn Court Nursing Home

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What the care home does well The home is calm and welcoming with staff professional in their manner. Staff said: "have worked here for four years, I love my job" Everyone has their needs assessed before they move in to the home so that they know their needs can be met. People said: "The staff attend to my medical needs fully and promptly." "Staff are nice, helpful" People feel that staff look after them well and relatives also have confidence in the service. The manager is committed to improving the service and supporting the staff in providing a good service to people. What has improved since the last inspection? The new manager has worked hard since the last visit and all the requirements and recommendations have been met. The manager provides clear leadership to staff and staff morale is improved. People living at the home are cared for by well trained and well supported staff. Staff said: "The home is a lot better than last year. So nice and peaceful no tension." "Much improved since new manager put in place - eg. Staff morale improved" "The home is managed well and support is good." Information in the care plans about care needs and support is clear and up to date. This means that staff have access to clear information about how to look after people, so that care needs are not overlooked as they change. Risk assessments are fully completed and updated regularly. This means that people are safe and any identified risks are properly managed. Although we received some mixed views on the provision of food, there has been a full review of the provision and availability of food. This means that people are being provided with adequate quantities of suitable, wholesome and nutritious food available at times when they want it. People feel more able to raise concerns and that action will be taken. People said: "Generally my experience has shown me that the overall service has been very good." The level and range of activities and stimulation has improved. This means that people have access to an increased range of different activities and stimulation. What the care home could do better: The new manager is clear about what she needs to do to make sure that the service provided to people living at the home continues to improve.The monitoring systems in place will help her identify areas to improve and will demonstrate where improvements are made. People told us that although staff were `usually prompt` they sometimes had to wait for call bells to be answered. The manager has identified an issue with the staff being able to hear the call bells easily and is in the process of addressing this with the provider. Key inspection report Care homes for older people Name: Address: Sabourn Court Nursing Home Oakwood Grove Leeds Yorkshire LS8 2PA     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Catherine Paling     Date: 2 0 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 30 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Sabourn Court Nursing Home Oakwood Grove Leeds Yorkshire LS8 2PA 01132658398 01132323025 ibrahisj@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd care home 49 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 49 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 49 Date of last inspection Brief description of the care home The home comprises of two buildings. Oakwood House dates back to the 19th century whereas Park House was purpose built more recently. The home is situated in a quiet location close to the main shopping area at the north end of Roundhay Road. Roundhay Park is also nearby and the home is close to a number of bus routes into Leeds and to surrounding areas. The home is registered for 49 places for older people with one place for a named young physically disabled service user and one for a named service user with Care Homes for Older People Page 4 of 30 Over 65 49 0 Brief description of the care home dementia. Accommodation is provided mostly in single rooms, the majority of which have en-suite facilities. There are some shared rooms available all of which have ensuite facilities. Personal care with nursing is provided. There are spacious communal lounges and dining rooms in both houses and access to the attractive gardens and patio is by ramp or level access. Passenger lifts go to all floors accessed by service users. Information about the service and facilities is available in a statement of purpose and service user guide as well as a home brochure. The current charges range from £576.41 to £1094.10 per week. Additional charges are made for chiropody, hairdressing, aromatherapy and newspapers. This information was provided at the January 2010 inspection. The home should be contacted directly for up to date information about fees. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced visit by one inspector who was at the home from 09:30 until 17:00 on the 20th January 2010. As part of the inspection process an expert by experience was also at the home for part of the day. An expert by experience is a person who has experience of using a care service. Because of this they can help an inspector get a picture of what it is like to live in the home. They produce written information for the inspector some of which is included in this report. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance Care Homes for Older People Page 6 of 30 with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and staff. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a self-assessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home, visitors and healthcare professionals who visit to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned by the time of this visit. Comments received appear in the body of the report. Care Homes for Older People Page 7 of 30 What the care home does well: What has improved since the last inspection? What they could do better: The new manager is clear about what she needs to do to make sure that the service provided to people living at the home continues to improve. Care Homes for Older People Page 8 of 30 The monitoring systems in place will help her identify areas to improve and will demonstrate where improvements are made. People told us that although staff were usually prompt they sometimes had to wait for call bells to be answered. The manager has identified an issue with the staff being able to hear the call bells easily and is in the process of addressing this with the provider. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. People have enough information to enable them to decide whether to the home is suitable. People have their needs assessed before moving into the home. We have made this judgement using a range of evidence, including a visit to this service. Evidence: The manager wrote in the AQAA: Comprehensive written information is provided to all prospective clients, outlining the ethos of Bupa Care Homes and the home, as well as vital information to help with the process of choosing a care home. The homes CSCI reports, the Service User Guide and Statement of Purpose are made available in reception. Prospective residents who are unsure are given the option of a trial in the home, to ensure their happiness and wellbeing. Regular mystery shops are conducted Care Homes for Older People Page 11 of 30 Evidence: to ensure the home is providing the correct information to enquirers. All required staff undertake enquiry training. We provide details of other Bupa homes in the area. We actively encourage enquirers to look at other homes so an informed decision can be made. Information in our surveys told us that the majority of people felt that they had been given enough information about the service before taking the decision to move in. There is a new brochure currently being produced that will be available soon. We looked at the pre-admission assessment documentation on the file of someone recently admitted to the home. We saw that there is a detailed assessment of peoples care needs before they are admitted to the home, shortly after admission and on a regular ongoing basis. Assessment information is also gathered from other sources and healthcare professionals. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. Care plans contain enough information for staff so that they know how to look after people properly. People living at the home get the care they need and are treated with respect. People are protected by safe medication practices. We have made this judgement using a range of evidence, including a visit to this service. Evidence: The manager wrote in the AQAA: All residents have comprehensive Personal Plans produced with the help of the QUEST assessment tool, which are reviewed monthly and updated as necessary. The Royal Marsden Manual is available to staff. Regional and National specialists are available for consultation. We record and report on the treatment of pressure ulcers, as well as assess and document actions taken to alleviate the risk. All residents nutritional needs are assessed using a recognised nutritional assessment tool. All residents are registered with their choice of GP. Care Homes for Older People Page 13 of 30 Evidence: Resident care is focussed on being person centred, supported by the Personal Best programme. Monthly audits are conducted by the regional manager assessing many aspects of care to allow continual quality assessment and improvement. This is in addition to the Reg 26s and also detailed audits on specific aspects of care done at home level (medication, care planning etc). A regular overview on the quality of resident care is provided by the regional manager, regional director and the Quality team. The Key Operating Guides have been developed to ensure best practice in selected aspects of care, giving the required information at point of delivery. There are comprehensive policies and procedures which are regularly reviewed. The BNF is available for use. Audit framework for care records. Care plans are also audited one week following admission to ensure that all mandatory information is in situ and all care plans are completed. People said in surveys: I have always maintained that a nursing home is only as good as its carers. At the moment, and this is the first time in 7 years, I feel that Oak House is now calm and the present carers work very well together. Because of this the service provided is much better. We also have good support from St Gemmas and the local surgery. The nursing is caring and the unit nurse is a delight. Provides a caring, safe, secure environment in order to bring maximum comfort and peace of mind to both the residents and families. Caring people, nice nurses, good with dad, beautiful place. Irritations - wheelchairs could be much cleaner; prompter attention to my (relatively infrequent) buzzer calls. The staff attend to my medical needs fully and promptly. Staff are nice, helpful We looked in detail at the individual care plans of two people from each of the two houses and briefly at the care of a fifth person. The standard of recording has improved since the last inspection. One member of staff told us that they had been given a lot of training to help them improve their record keeping. The improvement in record keeping means that staff have access to good information about how to look after people. Care plans included clear information about personal preferences and evidence of the involvement of the individual and/or their relatives. For example, one person prefers female carers and this was clear in the records. One person was not able to communicate verbally and there were good instructions for staff on how to approach this person, saying that they respond to touch, a smile and eye contact. It was also noted that this person became irritable when tired and that resting on their bed after meals improved this. We saw that a range of risk assessments are completed for people including the risk of skin damage, nutritional risk and moving and handling risk. Where risk had been identified there was a plan in place giving staff instruction on how best to manage the Care Homes for Older People Page 14 of 30 Evidence: risk. Records showed us that there are good communications with healthcare professionals with clear records of the input from general practitioners (GPs). Care plans are reviewed regularly. Staff need to take care that reviews do not become repetitive and fully review the effectiveness of the plan for the pervious month highlighting any changes. We looked at medication administration record (MAR) sheets and there were no gaps in recording. Where medication had been omitted the reason was clearly recorded. Regular audits of the medications are completed as part of the overall monitoring of the service. Staff involved in the administration of medication have received training and update. Healthcare professionals said in surveys: I have been involved in the care of one of the residents in this care home over the past eighteen months. The care provided has been of high quality despite increasing physical symptoms. Good holistic care of the resident described above. The expert by experience spoke with a small number of people and observed some care practices: All the residents looked clean and tidy and were nicely and appropriately dressed. I noticed several residents being lifted from their chairs by means of a body sling and hoist. This was done by two staff. This was unhurried and residents seemed quite relaxed about the procedure. I heard staff talking to the residents whilst moving them telling them what was happening - going up going down She also noted that people in their bedrooms had call bells within reach and staff were visible in all the areas she visited. However, although some people said that staff were usually prompt, a small number of people said that they sometimes had to wait a long time for the buzzer to be answered. People in their bedrooms also said that staff did pop in to see if they were ok although this was not formally recorded. One person added someone comes in to say goodnight Comments made to the expert by experience included: suits me home excellent nice room happy with way relative dealt with very comfortable everything done for you overall quite happy. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. People are encouraged to make their own decisions about their lifestyle. Family and friends are welcomed at the home. People are provided with a varied diet taking into account personal preferences. We have made this judgement using a range of evidence, including a visit to this service. Evidence: The manager wrote in the AQAA: We ensure that all Personal Plans are individual and based on the choices and preferences of the residents. Should they choose to do so, residents are encouraged to handle their own finances. We encourage the personalisation of a residents personal space, giving somewhere they can really feel at home. We have developed our menus to allow for resident choice and preferences. We employ an open visiting policy, taking into account residents wishes. The menu master helps ensure every menu within the home is customer led and nutritionally balanced. The Nite Bite menu allows our residents to choose what to eat when they feel like it, providing healthy choices at any time through the night. We provide Care Homes for Older People Page 16 of 30 Evidence: picture menus to help open up choice. We encourage the involvement of residents and staff in the development of the menus. We have a structured activities programme, with a dedicated activities organiser. We encourage a weekend activities programme. People said in surveys: When residents are given coffee and tea at morning and afternoon breaks and also at supper time they very rarely give the residents plates to use with biscuits or cakes, which I find annoying, as elderly people are unable to balance cake etc on a serviette. I have raised this point on occasions and it remedies itself but soon reverts back! Would like a bit more entertainment at the weekends. make sure there is a member of staff at all times where the residents sit. Regular stimulating activities. In the warmer weather it would be nice for the residents to be out in the fresh air under new umbrellas and extra seating. We have complained before about the fillings in the sandwiches and variety of foods given at meal times. Make arrangements for a religious service every month or for potential visit from a vicar or similar. Could provide a better vegetarian menu People spend their day either in the lounge areas or in their rooms. Since our last visit a new activities person has been appointed and progress has been made on the provision of varied activities and stimulation for people both in the lounge areas and for those who stay in their rooms. The activities person was on leave on the day of our visit but arrangements were in place for the activities person from one of the sister homes to provide some cover. During the morning this person was on Park House reading out articles from the newspaper which was sparking chat amongst people and stimulating memories. In the afternoon we saw the activities person visiting some people in their bedrooms taking books and quizzes to them. The homes own activities person had arranged some outings, including a trip to the Christmas lights and to a local garden centre. These had proved to be very successful and more are planned. In addition social evenings are also held proving an opportunity for families and friends to come to the home and enjoy a social event. A Burns night supper was being planned. Staff said in surveys (need to) Work more closely with the local community. This has however more recently improved with interaction with local schools, the local brownie group. Comments from expert by experience: Comments from residents as to what they do all day included knit watch TV and read but staff come and tell me what activities are going on (but said chose not to take part or go on the outings) another said there were no activities - just read and watch television another said they do nothing but Care Homes for Older People Page 17 of 30 Evidence: there has been bingo, cards and dominoes using big cards and there had been a trip to a garden centre with fish and chips afterwards; One resident who stays in room said they read but Tony brought in quizzes and another who stays in room reads the papers watches tv did crosswords and also got quizzes from Tony. Another comment was resident didnt like going into lounge as everyone was asleep. A resident in Park House said the home had made her a birthday cake and the staff had come in to sing Happy Birthday; there was a comment there were no church services but Salvation Army did come in at one time and resident enjoyed this. When we spoke with the manager she told us that the Salvation Army did still visit the home so we suggested that maybe this event needed more publicity so that those who wanted to take part could do so. The lunchtime meal looked and smelt appetising and people seemed to enjoy the food. We were told that there is a range of snacks left for people to have overnight if they are hungry; this was confirmed in comments made to the expert by experience. Although we did receive some mixed comments about the food there does seem to have been an overall improvement. The meal time was managed in a more relaxed manner. Comments from the expert by experience: I had lunch in Park House. Lunch was organised and unhurried; the dining room was pleasant and tables nicely set. I was told meals were chosen the day before and there was usually a choice of two hot meals at lunch and tea time (although there was no choice of lunch on Wed and Sundays) Staff said if there was nothing a person liked they could choose something different and this was confirmed by a resident. The meal was hot and nicely served. Water or juice was served with the meal and tea afterwards; a resident who wanted tea with her meal was brought a cup. On one table two residents were assisted with their meals by two carers on a one to one basis, but on the table I was on one carer sat between two residents and assisted both at the same time. Staff asked some residents if they would like help in cutting up their meat. One meal served in pureed form was nicely served, the meat, potatoes and vegetables all being identifiable on the plate. One plate had a stand up collar to make eating easier for the resident. Two residents ate in the lounge; their meals were nicely served on trays. Those I spoke to all said they enjoyed their meal. One resident felt staff did their best with vegetarian diet; and there had been some improvement We saw that there was fresh fruit available in Oakwood house and were told that some people had fruit as an alternative to the pudding. One person told us that they sometimes get fruit offered in an afternoon and another said that they get bananas Care Homes for Older People Page 18 of 30 Evidence: but not apples or oranges. The expert by experience spoke to people about making choices in their care. Comments from expert by experience: All the residents I spoke to said they could get up and go to bed when they liked and one said staff would come back later if not ready to go to bed. There were mixed comments made regarding choices in relation to baths and showers. Overall, it seems that people felt that they could have a bath or shower when they wanted to. Some said that they would prefer a bath but were given a shower; another person was helped with an all over wash and did not get a bath or shower but didnt seem sure why. The manager told us that the number of hours available for activities had increased since the last inspection and she was in the process of providing an activities person for each of the two houses Care Homes for Older People Page 19 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. People can be confident in raising concerns on a day to day basis and they have access to a formal complaints procedure. People are protected by staff knowledge and understanding of safeguarding. We have made this judgement using a range of evidence, including a visit to this service. Evidence: The manager wrote in the AQAA: Bupa Care Homes has recently reviewed its complaints policy. The current policy has agreed timescales for managing complaints. The information that accompanies the policy is prominently displayed in the home. The policy includes a two -tier framework including the home and the regional management team. Bupa Care Homes has robust allegation of abuse and neglect policies, allowing staff to raise concern within the home or to senior staff outside the home. The PoVA procedures are well documented should the need arise. Whistleblowing policy. Bupa Care Homes has a national team of Quality experts available to provide advice and help where needed. Training is available regarding to all aspects of protection. We saw that the complaints procedure is displayed in the entrance area to the home. Care Homes for Older People Page 20 of 30 Evidence: It is a clear and well established procedure. There have been fewer complaints since our last visit and people said that they felt more confident that their concerns were being listened to and dealt with. Our surveys told us that people felt able to talk to someone informally about concerns but that not everyone was aware of the complaints procedure. We have received one concern from a relative since the last visit. There was dissatisfaction with the initial response from the service. However, the concerns were re-investigated by the provider and a further response was made, which was satisfactory. The complaints log showed us that concerns are taken seriously and dealt with properly. We saw information from a relative referring to the vast improvement in the last six months in response to concerns about catering. We spoke to staff and they told us about safeguarding training and training around the Mental Capacity Act and deprivation of liberties safeguards. This training will ensure a greater understanding of individual right and liberties. We saw from records that any safeguarding incidents are taken seriously with advice and input sought from the local authority. The service also tells us about any incidents, as they are required to do. Care Homes for Older People Page 21 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. People live in a safe, comfortable and well maintained environment. We have made this judgement using a range of evidence, including a visit to this service. Evidence: The manager wrote in the AQAA: We use a specialist microfibre cleaning system that combined with effective cleaning regimes keeps the home clean and odour free. Our comprehensive policies and procedures include infection control and handling clinical waste. Services and facilities comply with the Water Supply (Water Fittings) regulations. The home is supported in maintaining the environment by a central team of experts. We have a specialist property and estates department as well as a hotel services department. Regional Managers visits focus on the standard of housekeeping. EHO rating is 5. Bupa SOP (Surveying Our People), which indicates service users satisfaction with regards to the environment. We visited all areas of the home used by the people who live there. The home was clean and odour free. The grounds are attractive and there are seating areas on the paved areas outside Park house and in the gardens to the side of Park House. Care Homes for Older People Page 22 of 30 Evidence: We saw good infection control practices and staff have had training in infection control procedures. Comments by expert by experience: clothes looked clean and pressed; one resident said only one item gone missing but they had no complaints; no-one else had complaints about the laundry The manager told us that there have been issues identified with the call bell system, which mean that staff cannot always hear it when they are in bedrooms. This means that there can be delays in staff response at times. Work to replace the nurse call system is due to commence in March. Care Homes for Older People Page 23 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. People are looked after by trained and competent staff. People are protected by robust recruitment systems. We have made this judgement using a range of evidence, including a visit to this service. Evidence: The manager wrote in the AQAA: Bupa Care Homes has comprehensive Human Resource policies and procedures to aid staff management and recruitment. We endeavour to maintain agreed staffing levels at all times. We perform appropriate CRB, PoVA and NMC PIN checks on all staff. There is a training matrix specific to the home that identifies the training requirements of staff. We have a good level of staff retention. We have a unified style and format for staff files. We have an improved skill-mix. All mandatory training is up-to-date. Comprehensive Whistleblowing Policy. Bupa Care Homes has received IIP accreditation and it has been reviewed since 2003. There seemed to be enough staff to look after the people in the home at the time of Care Homes for Older People Page 24 of 30 Evidence: our visit. Some people commented that sometimes staff seem rushed but staff told us that they felt they were able to look after people properly. All the staff we spoke with said that they had plenty of training. This means that they have the knowledge they need to know how to care for people. Staff said in surveys: have worked here for four years. I love my job. Training records showed us that training is up to date and there is a training plan for 2010. We looked at the individual recruitment files of two recently employed staff and all the required checks are completed for people before they start work at the home. Comments from expert by experience: There appeared to be plenty of staff around in Park House when I was there and there was a staff presence in the lounges of both Houses when I visited. All the staff I spoke to were friendly welcoming and polite. In Park House the staff I came across spoke to the residents in a caring friendly and respectful manner and atmosphere felt comfortable. Comments made to the expert by experience: some staff ok friendly approachable staff nice/staff lovely Care Homes for Older People Page 25 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service experience good quality outcomes in this area. The home is well managed and is run in the best interests of the people who live there. We have made this judgement using a range of evidence, including a visit to this service. Evidence: The manager wrote in the AQAA: Regular Health and Safety meetings take place, with a standardised agenda giving staff the opportunity to communicate on Health and Safety issues. The minutes from there go to the Regional Manager and Quality team. There are regional and national experts available within the company for advice and guidance if required. The Home is supported by a national team of Quality Consultants whose role includes supporting quality issues within the home, auditing and providing guidance on policies, procedures and practice. There are dedicated Health and Safety Care Homes for Older People Page 26 of 30 Evidence: staff within the regions, supported by a National Quality team. This includes Health and Safety and Fire Management Leadership. Bupa Care Homes has a comprehensive suite of policy and procedure manuals that are regularly reviewed by experts and updated when required. We have an annual internal and external customer satisfaction survey. Bupa SOP (Surveying Our People) is conducted annually. The Personal Best programme encourages a person centred approach to all tasks. Staff meetings occur monthly. All staff are supervised. After our last visit the provider appointed a new manager at the home. She is an experienced manager and is registered with us as manager of the service. However, since her appointment and until very recently she has also been providing support to the two sister homes nearby. This has led to people feeling that they never see the manager. This situation is now resolved and she is now at the home full time. Despite the difficulties of not being at the home fulltime the manager has still been able to initiate improvements at the service for the people living there and the staff. Staff said: New manager great thats what we needed. The home is a lot better than last year. So nice and peaceful no tension. Happy home now. New manager easy to talk to always available Much improved since new manager put in place - eg. Staff morale improved The home is managed well and support is good. People said: Overall the service is reasonable and no one item of service comes to mind as outstanding. Generally my experience has shown me that the overall service has been very good. There is a comprehensive system of audits carried out regularly to help the manager in the ongoing monitoring of the service and these include seeking the views of the people who live at the home. The results of these audits show that there is an increasing satisfaction with the service provided at the home. Care Homes for Older People Page 27 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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