Inspection on 24/05/05 for Borovere

This inspection was carried out on 24th May 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Borovere 12/07/06

Borovere 19/01/06

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 Unnannounced 24.05.05 10:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Borovere Address 10 Borovere Lane Alton Hampshire GU34 1PD 020 7793 1122 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Greensleeves Homes Trust Mrs Edith Wilson Johns CRH 30 Category(ies) of Old Age - OP - 30 registration, with number of places Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16/11/04 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. Greensleeves has recently taken over the ownership of Borovere. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for the year 2005/2006 and was unannounced. It was completed over six hours. The focus of the inspection was to talk to residents about how the home meets their needs and what it was like to live at Borovere. A tour of the premises found the home to be clean, homely and decorated and furnished to a high standard. Five service users were spoken to and in general were happy in the home and felt their needs were met. Three staff were spoken to and were able to tell the inspector how they meet the needs of service users. Some staff commented that they were unsure of how the change of ownership would impact on their jobs. What the service does well: What has improved since the last inspection? The home is in a state of flux since the takeover last month by Greensleeves. Some of the paperwork due to be put into place was available to look at but none are currently working documents so it was not possible to say yet whether they will make an improvement. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 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 H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4. Standard 6 does not apply. The use of an admission procedure and pre admission assessment ensure that only residents whose needs can be met are offered a place in the home. EVIDENCE: Assessments of prospective service users are undertaken prior to admission. Service users spoken to confirmed that either they or their relatives had the opportunity to visit the home before making a decision to move in. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 11. The arrangements for care planning need to be improved to ensure that the changing needs of service users are recognised and recorded. Procedures in place for healthcare and medication ensure that service users medical needs are met. EVIDENCE: Each service user has a basic care plan in place. A format that is to be introduced by the new company was seen to be more detailed. Nine care plans were seen and none of them showed any evidence of having been reviewed regularly. One had not been reviewed since November 2004. A new requirement was made to keep all care plans under regular review. There was no evidence that service users or their representatives are involved in the care planning process. A new requirement to meet this standard has been made. Service users are registered with a local General Practitioner and records showed when Doctors had visited and any outcomes. Service users spoken to stated that they are able to access healthcare professionals and felt confident in the homes’ ability to meet their health needs. Medication was seen to be administered appropriately via the Monitored Dosage System. A sample of current stocks showed they matched the records Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 10 held. Discussion with staff showed that only those with appropriate training administered medication. A new lockable fridge was seen to be used for the safe storage of medication, as required at the last inspection. A requirement for a lockable drawer to be provided to a service user who self administers has not yet been met. Nor has the necessary risk assessment been drawn up. At the last inspection it was recommended that service users’ wishes regarding death and dying are recorded and held on their files. The new company’s care plan format includes a space for this. It was also seen to be recorded in respect of new service users. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Arrangements for more recreational activities and entertainment in the home would benefit service users. The visiting policy ensures contact is maintained with families and friends. Arrangements for mealtimes are suited to the service users. EVIDENCE: Three service users stated that there was not enough to do and they would like more entertainment in the home. One staff member stated she did activities with service users, but there was no written record of regular activities being offered and how many attended. There was no evidence of outside entertainment being brought into the home on a regular basis. Service users stated that they may receive visitors and that they are made welcome. Some service users said they could access the community with their family members. Menus showed that a variety of wholesome and nutritious food is offered. Individual likes and dislikes are written on a board in the kitchen. The chef was able to demonstrate how specific dietary needs are met, for example, diabetic and low cholesterol diets. Although no cultural or religious diets are currently catered for the chef stated the need could be met in the home if requested. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 12 Four of the five service users spoken expressed great satisfaction with the food. One service user told the inspector she had asked for more soup to be available, records showed that this had been addressed. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 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 standard(s) None of these standards were assessed on this occasion. EVIDENCE: Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 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 standard(s) 19, 25 and 26 The cleaning and maintenance arrangements for the home ensure that service users live in a hygienic and safe environment. EVIDENCE: The home has extensive well kept grounds which service users can enjoy when the weather permits. Inside the home is also maintained to a high standard. The home was seen to be kept clean throughout. The home provides suitable laundry facilities and the kitchen was seen to be clean and hygienic. Staff were seen to be wearing hats and aprons. The Environmental Health Officer visited on may 20th 2005, four minor requirements were made, for example, repainting window sills. The home was awarded the Food Hygiene Standard Award. A requirement stating high-risk radiators must be covered had not been met. Risk assessments had been carried out and high-risk radiators had been identified. Quotes for these are currently being sought. On the day of inspection the weather was mild and no radiators were on, therefore there was no immediate risk to service users. A new requirement has been made. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 15 Also, a requirement for risk assessments on all windows to be undertaken was made at the last inspection. A quote for window locks was seen but no risk assessment was available. A new requirement has been made. Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed. EVIDENCE: Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed. EVIDENCE: Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x 2 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 19 yes 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 OP7 Regulation 15 Requirement Care plans must be regularly reviewed and show evidence that service users or their representatives are involved in this process. The home must refer to 5.1 of the Royal Pharmaceutical Society guidelines for the Administration of Medicines in Care Home to ensure safe storage of medication kept by a service user and refer to 6.2 of the guidelines to ensure appropriate risk assessments are in place. THIS IS AN OUSTANDING REQUIREMENT FROM THE LAST INSPECTION. Service users must be consulted on their preferences for activities and a programme of recreation and fitness drawn up. The home must put into place a plan of action to ensure the safety of service users with regard to the windows identified as high risk. THIS IS AN OUSTANDING REQUIREMENT FROM THE LAST INSPECTION. The home must put into place a contingency plan of how it plans to protect individual service Timescale for action 31/07/05 2. OP9 13 30/07/07 3. OP12 16 (2) (n) 31/07/05 4. OP 25 13 31/07/05 5. OP25 13 20/07/05 Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 20 users from burns from radiators assessed as being of high risk until the radiators are covered. THIS IS AN OUSTANDING REQUIREMENT FROM THE LAST INSPECTION. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Borovere H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 H54 S63367 Borovere V227163 250505.doc Version 1.30 Page 22 - 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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