Inspection on 12/07/06 for Borovere

This inspection was carried out on 12th July 2006.

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

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

Other inspections for this house

Borovere 19/01/06

Borovere 24/05/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Borovere 10 Borovere Lane Alton Hampshire GU34 1PD Lead Inspector Keith Hopkins Unannounced Inspection 12th July 2006 11:00 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 Borovere DS0000063367.V299321.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. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Borovere Address 10 Borovere Lane Alton Hampshire GU34 1PD 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) 01420 85048 Greensleeves Homes Trust Mrs Edith Wilson Johns Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Borovere Residential Home is a care home providing personal care and accommodation for up to 30 older people. The home is located in the town of Alton and is situated in its own landscaped gardens in a quiet residential area not far from the town centre. The house has been extended to provide 26 single rooms and two double rooms; the double rooms are only used as doubles if a request is made for shared accommodation. Fees range from £495 to £550 per week. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Six hours were spent visiting the home, during which time the opportunity was taken to look around the home, view records and policies and to talk to the manager. The inspector also spoke privately with two members of the care staff and the cook. Most of the service users were observed making use of communal areas and their bedrooms and a number were spoken with briefly. Four service users were spoken with at greater length in the privacy of their bedrooms, and the inspector was also able to speak with a visitor. What the service does well: What has improved since the last inspection? Service users’ safety has been enhanced through the fitting of covers to radiators, and new staff now receive improved induction training. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 6 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. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has assessed the needs of its current service users well. These needs are clearly recorded and known to staff. EVIDENCE: Four service users’ files, one relating to a more recently admitted person, were inspected and needs assessments seen within these files contained a good level of detail. There was, for example, information regarding sight, hearing, mobility, and promotion of continence. The more recently admitted service user confirmed that she had been visited by staff in her own home before going into Borovere and that she had also viewed her room beforehand. The manager explained that it was usually herself together with the expected key worker who undertook the initial assessment prior to any decision regarding admission. A member of staff confirmed this. The inspector also saw evidence that assessments were reviewed after admission, and service users spoken with confirmed their involvement in the assessment and review process. One Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 9 person, for example, said that she had had her photograph taken and had ‘never felt such a celebrity’. Staff spoken with were clearly aware of the needs assessments. The cook, for example, explained that when a new person moved in she was made aware of any particular dietary requirements. The home does not admit service users for intermediate care. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good care planning regime, which addresses identified personal, social and health care needs and involves service users. EVIDENCE: Three care plans were examined and contained information for staff to ensure that all aspects of health, personal and social care needs could be met. Plans are reviewed on a regular monthly basis and service users confirmed their involvement in this process. Staff and the service user sign reviews. Service users also said that staff knew how to help them. One person, for example, said that the staff ‘encourage me to do things’ and that they ’help me if I need it’. Another service user confirmed that staff helped him when he wanted to have a bath. Plans contained information regarding more specific needs such as chiropody and dentistry. Some service users, for example, access these services Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 11 externally rather than ‘in-house’. Service users also confirmed arrangements to access a GP with one saying ‘they get the doctor whenever I need it’. The home has a policy and procedure for dealing with medication, which enables service users to exercise choice over whether they wish to deal with their own medication. A service user currently doing this said that he had a secure place to keep his medicine and showed the inspector this. A risk assessment was in place regarding this. Other service users commented that they were happy for the home to deal with their medication. The drugs cupboard, including the separate controlled drugs cabinet, was secure at the time of the inspection. Records relating to two service users were examined and were in order and up to date. A check was made on one person’s controlled medication with the amount tallying with the record held. Medicines requiring refrigeration were kept in a separate dedicated fridge and the temperature of this was regularly checked. Staff responsible for dealing with medication have been trained. A visitor to the home said that she was very happy with the care provided for her mother and that there was nothing that could be done better. Staff were observed to be providing assistance to service users in a calm and dignified manner, and knocked on doors, awaiting a response, before entering. Service users’ wishes regarding the way in which they are addressed by staff are recorded in their care plan and respected by staff. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy varied lifestyles and undertake activities of their choice. Visitors to the home are encouraged. Service users enjoy attractively presented meals in congenial surroundings. EVIDENCE: Care plans clearly detail what each service user’s interests are and service users themselves confirmed, variously, that they enjoyed activities such as reading and listening to music. An ‘Activity Questionnaire’ is given to all new service users who are asked to tick the various activities on offer or suggest others. The home aims to have an activity on most days and activities undertaken the previous month included a quiz afternoon, a scrabble afternoon and a film afternoon. One service user confirmed that Communion is held every Friday in the home and another that he attended a local Methodist church. The inspector spoke with one visitor to the home who was pleased with the services offered to her relative. Service users were observed during the Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 13 inspection to be entertaining their visitors either in the communal areas of the home or in private in their bedrooms. Service users are able to move freely around the building and were seen to be making use of all communal areas as well as their bedrooms. Menus at the home were varied and the inspector observed an attractively presented meal being served in the dining room at lunchtime. Staff were observed to be providing assistance in a discreet and dignified way to service users who needed help with eating. The dining room was well-decorated and laid out with flowers on each table. It was clear from observation that meals were very much a social occasion with a great deal of conversation taking place. One service user confirmed that the food was good and that choices were available with an alternative to the midday meal being offered if need be. Service users are encouraged to take meals communally in the dining room but may use their own rooms if they wish. The cook was clearly aware of individual needs and choices, which were met, and a record was kept of these. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a suitable complaints procedure, which service users are aware of and feel able to use. Service users are protected through an adult protection policy and procedure known to and understood by staff. EVIDENCE: The home has a complaints policy and procedure, a copy of which was included in the information available to potential service users. One service user recalled that a copy of the complaints procedure was included with his contract when he moved into the home. Two of the service users spoken with privately said that they had no complaints and were aware of what to do if they had. Service users all appeared to have a good degree of confidence that any issues raised would be dealt with, although it was reported by the manager that the home had had no complaints to deal with in the previous 12 months. One service user commented that he had raised an issue with the home regarding meals and had received a satisfactory response to a query. Staff when interviewed said that they would report to a more senior person any complaints made to them by service users. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 15 The home also has a policy and procedure relating to adult protection, with information produced by Hampshire Social Services being available for staff to consult. Staff have been trained in this and when interviewed confirmed their understanding of what to do in the case of suspected abuse. Both members of staff interviewed said that they would report anything they needed to. Borovere DS0000063367.V299321.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable environment, which is suitably furnished and well maintained. EVIDENCE: The tour of the building showed this to be clean and tidy throughout and there were no undue odours. Communal areas were well furnished and adequate bathroom and toilet facilities with aids were available. Communal areas include an attractive, light and airy dining room and a well-furnished lounge. The inspector visited four service users in their rooms, which were all adequate in size, and had clearly been personalised, to considerable degrees. Comments made variously by service users included that it was ‘nice to have my own bathroom’, with one service user saying that she was ‘pleased with the room’. Service users were observed to be freely making use of communal areas, such as the lounge and other communal areas and accessed their bedrooms as they wished. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 17 The home’s laundry was inspected and was fit for purpose with machines being capable of meeting disinfection standards. Members of staff spoken with were clearly aware of good practice and there were procedures in place to deal with soiled items. Staff were aware of these procedures and confirmed that gloves and aprons were available. The building is well maintained with a full time handyman to deal with day-today matters. The manager said that there was good support from the provider in dealing with items requiring attention and that she had delegated financial authority to deal with anything costing less that £500. All radiators have been covered since the last inspection following a requirement. During the tour of the building the inspector found the temperature of the water at two wash hand basins in bathrooms on the first floor to be unacceptably hot. The manager agreed to investigate this. Borovere DS0000063367.V299321.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers. Service users are protected through the soundness of the home’s recruitment practices but all staff need to have had induction training. EVIDENCE: Three staff files were inspected, all relating to staff employed within the last year. These contained evidence of written references being obtained following the completion of an appropriate application form and interview. There was evidence of Criminal Record Bureau (CRB) disclosures having been obtained, and one staff member said that the home had, following a successful interview, told her that she could not start work until her CRB check had come back. Staff have job descriptions and one staff member confirmed that ‘shadowing’ a more experienced person formed a part of her induction programme. Files contained evidence of the various short courses undertaken which included First Aid, Basic Food Hygiene, Fire Prevention, Moving and Handling, Supervision and Appraisal and Abuse Awareness. The home has a training plan, which includes induction for new staff. At present the home is working through induction training for all staff to ensure that longstanding staff have covered the same topics Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 19 as new staff. This follows a requirement raised at the previous inspection. Staff files examined confirmed the home’s supervision and appraisal system, staff being supervised every other month. During the inspection the inspector observed staff members interacting with service users in a friendly yet professional manner. It was explained to the inspector, and confirmed by the rota, that there were usually four or five members of care staff on duty in the mornings and three in the afternoons who were backed up by ancillary staff. There are two members of staff on waking duty at night. Staff were observed to be attending to service users’ needs in a calm and unhurried manner, although said that they were busy at times. Service users without exception commented positively about staff saying variously that ‘nothing is too much trouble’, that the ‘staff are wonderful’ and that ‘staff know how to attend to my personal needs’. One service user said that staff came immediately when he had an accident. It is understood that almost 50 of the care staff have a National Vocational Qualification at Level 2 and that two further staff are undertaking this. Borovere DS0000063367.V299321.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a qualified and competent manager, supported by comprehensive policies known to staff. EVIDENCE: The home’s manager has worked in the home for a considerable number of years and has obtained the Registered Manager’s Award. An annual review of the home’s services is undertaken by way of a questionnaire to service users, with the next review due at the end of the month. Additional, more specific surveys are made on occasion. For example, on 17th May 2006 a survey was undertaken regarding food. Twenty replies were received, all commenting positively. Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 21 The home does not deal with any service users’ monies, and any sundries purchased on behalf of service users are billed separately. The home has a policy for the control of substances hazardous to health known to staff. Chemicals and other items were securely stored in locked cupboards and staff were aware of health and safety issues. The home has a health and safety policy known to staff. A sample of policies, procedures and records required by regulation were inspected and were in order and up to date. This included the home’s fire records and accident book. Borovere DS0000063367.V299321.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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13 Requirement Risk assessments must be undertaken on wash hand basins in bathrooms and thermostatically controlled mixer valves fitted where needed. Timescale for action 31/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Borovere DS0000063367.V299321.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Borovere DS0000063367.V299321.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. 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