Inspection on 19/01/06 for Borovere

This inspection was carried out on 19th January 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 12/07/06

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 Liz Palmer Unannounced Inspection 19th January 2006 10:25 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.V257275.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 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) 020 7793 1122 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.V257275.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 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. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Greensleeves has recently taken over the ownership of Borovere.This was the second inspection for the year 2005/2006 and was unannounced. Any key standards not assessed on this inspection were assessed at the previous inspection. Therefore, this report should be read alongside the previous report. The inspection took place over one day and took five hours and twenty minutes. Three staff and three residents were interviewed. Eight relatives’ comment cards were returned as were six from service users. What the service does well: What has improved since the last inspection? Care plans have greatly improved providing much more detail and are being regularly reviewed. An activities programme has been developed offering more opportunities for stimulation to residents. A resident who self-administers medication has been provided with a lockable cabinet to store their medication. Window catches have been fitted to all windows to ensure the safety of residents. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 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.V257275.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed. EVIDENCE: Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 10. Improvements to care plans ensure resident’s needs are set out clearly and reviewed regularly. The arrangements for personal care ensure resident’s privacy and dignity is respected. EVIDENCE: Three care plans were looked at and seen to be a great improvement since the last inspection. They are more detailed, including a family history, previous employment, hobbies, interests, daily routines and the care needed by the individual. Staff said they are finding them good to work with and are reviewing them monthly. They are reviewed every three months with the resident and a family member. Staff spoke about and to residents in a respectful manner during the inspection. Staff were seen knocking on resident’s doors before entering. Residents said they felt their privacy and dignity was maintained by staff. For example, one said they appreciated their freedom to have their own telephone another to be left to spend time alone in their room. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14. Action to address a requirement for a program of recreation and fitness to be drawn up has improved the activities in the home. Arrangements are in place for service users to have choice and control. EVIDENCE: One staff member is responsible for organising activities in the home. She has been on a suitable training course and was very enthusiastic about what she had achieved so far and her future plans. A record has been kept of all activities held and who attended. Activities include, a knitting circle, poetry readings and board games. It is planned that one activity takes place per day. This meets the requirement made at the last inspection. Staff said that since Christmas it hasn’t been possible to put on all the activities planned due to staff shortages and agency staff working in the home. This will be resolved once the home is fully staffed again and will be monitored at future inspections. Two of the residents spoken to said they were aware of the activities but choose not to join in as they prefer their own company. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 11 Residents are able to access advocates and external legal advice if they need it. Two of the residents spoken to said they had family members with Power of Attorney and would seek any financial or legal advice through them. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 12 Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 13 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, 17 and 18. Procedures for complaining promote the rights of residents and their representatives. Resident’s legal rights are upheld by arrangements in the home. Arrangements are in place to protect residents from abuse. EVIDENCE: A suitable complaints procedure is available in the home. No complaints have been recorded since the last inspection. Residents spoken to said they knew how to make a complaint and felt confident that any issues would be sorted out informally. Resident’s were able to give examples of issues they had raised with the home that had been addressed to their satisfaction. Staff said they were aware of the homes’ complaints policy and how to support residents if they wanted to make a formal complaint. From discussion with staff and residents it appeared that informal complaints are dealt with appropriately by the staff and management of the home. Residents are supported to manage their own finances and those needing it get help from their families. One resident said they were on the electoral role and would therefore be able to vote if they chose to do so. Staff said they had attended a two day ‘abuse’ course and were aware of the homes’ adult protection policy. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 14 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): 25. A requirement for radiators to be risk assessed was made at two previous inspections. This aspect of the standard was inspected. Resident’s would be more safe if all radiators were covered following risk assessment of this need. EVIDENCE: A requirement made at two previous inspections for a plan to protect residents from burns from radiators has been partially met, in as much as high risk radiators have been identified and furniture put in front of them. The manager stated that she had gained quotes for all radiators to be covered in the home and was waiting for agreement from Greensleeves. A requirement has been made for the high risk radiators to be made safe. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Residents would benefit from a full complement of permanent staff. Recruitment procedures are generally robust but must be followed at all times to protect residents. Improvements to the induction and training would ensure that residents are supported by competent well trained staff. EVIDENCE: Seven care staff have left the home since the last inspection. The manager stated some problems she has had in recruiting new staff over the last six months. More recently, there has been a better response and interviews are being arranged to fill the remaining vacancies. The home is currently 200 hours per week under the staffing levels recommended by the residential forum. This is currently being filled by agency staff. Staff spoken to mentioned some of the difficulties they had experienced working with agency staff but it does not appear to have impacted on residents. They spoke highly of all the staff who work in the home saying things like ‘they are all delightful’, ‘they work very hard’ and ‘I feel in safe hands at all times’. The home has a clear recruitment procedure which includes applicants filling in a suitable application form, two references being taken up and a criminal record check being carried out. It was noted that a recent employee only had one reference on their file. This was discussed with the manager and although this person does not have contact with residents it was agreed that in order for her to safeguard residents two suitable references must be received before a person starts their employment. A requirement was made. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 16 Of the staff spoken to two had achieved National Vocational Qualification (NVQ) level 3. All had been trained in infection control, manual handling, medication and dementia. Residents said they felt staff were well trained and competent. Through discussion with staff it was evident that they are able to carry out their roles with confidence. A comprehensive induction programme is not yet in place. The manager stated that a training budget is going to be set up for the next twelve months and part of that will include a ‘Skills for Care’ induction programme which all new staff will undertake. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 17 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. The home is well run and residents and staff have confidence in the manager. Results and an action plan following a quality audit would ensure the home is run in the best interests of residents. Residents’ financial interests are protected by the home’s procedures. Systems for maintaining safe working practices promote residents’ safety. EVIDENCE: The registered manager has been running the home for 17 years and has achieved her NVQ level 4, registered managers’ award. Residents spoken to said they had confidence in her to manage the home well. Staff also said they had confidence in the management of the home and felt able to bring up any concerns they may have and have them resolved. Residents have regular meetings to discuss the homes’ activities, the food and any other issues they wish to bring up. A record of these meetings was seen and residents said they were aware of them taking place. A quality audit Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 18 questionnaire was carried out in August 2005. Questionnaires were given out to residents and their relatives and staff. The results have not been collated yet. It has been recommended that this be done so that people’s views can be known and acted upon where necessary. Residents felt that they have enough say in the running of the home. The home does not keep any money on behalf of residents, all are supported by their families or an external representative. Policies and procedures are in place for health and safety, for example, staff receive training in manual handling, fire training is given and fire safety checks are carried out. Residents said staff wear gloves and aprons. Residents also said that they felt safe in the home and trusted the staff and management to carry out all the necessary precautions to maintain their health and safety. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 X X X X X X 2 X STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP25 Regulation 13 Requirement All radiators and other hot surfaces must be risk assessed and the risk of burns eliminated by covering or other means. THIS IS A REPEAT REQUIREMENT FROM THE LAST TWO INSPECTIONS. Two written references must be received for all new employees before they start their employment. A suitable induction programme including ‘skills for care’ must be in place and undertaken by all new staff. Timescale for action 30/03/06 2 OP29 19 31/02/06 3 OP30 18 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Borovere Refer to Good Practice Recommendations DS0000063367.V257275.R01.S.doc Version 5.1 Page 21 1 Standard OP33 Results of a quality audit should be available to residents and an action plan drawn up to reflect their comments. Borovere DS0000063367.V257275.R01.S.doc Version 5.1 Page 22 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.V257275.R01.S.doc Version 5.1 Page 23 - 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. 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