Inspection on 06/07/06 for Borrage House

This inspection was carried out on 6th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Borrage House 03/07/07

Borrage House 07/02/06

Borrage House 01/12/04

Borrage House 20/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Borrage House 8 Borrage Lane Ripon North Yorkshire HG4 2PZ Lead Inspector Mrs Irene Ward Key Unannounced Inspection 6th July 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Borrage House DS0000007958.V302836.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. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Borrage House Address 8 Borrage Lane Ripon North Yorkshire HG4 2PZ 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) 01765 690919 01765 600021 www.anchor.org.uk Anchor Trust Jean Rowlinson Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Borrage House is registered to provide personal care for 40 people aged 65 years and above. It is owned and operated by Anchor Trust. The Original building was a private dwelling house and built on three floors and a two-floor extension has been added at the rear of the site. The residents are located on the ground and first floors only and there is an eight person vertical lift to provide level access to the first floor. It is located near the centre of the city of Ripon and there is ample garden and parking space to the side and rear of the main property. The weekly fees on 16th June 2006 range from £317 to £465. This information was supplied to the Commission For Social Care Inspection via the preinspection questionnaire received on the 6 July 2006. Service users/relatives and other interested parties are able to have access to inspection reports as they are displayed on the service users notice board in the main hallway of the home. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit carried out on the 6 July 2006. This visit was carried out by one Regulation Inspector and started at 09.00 hrs and finished at 16.30 hrs with 3 hours preparation time. The inspection process included information provided by the home prior to inspection. Surveys were also sent to relatives and friends and health and social care professionals. Comments received from relatives and friends were on the whole positive although some concerns had been raised by relatives regarding sufficient staffing levels, security of the building and safety of service users in the kitchen. Comments received from health and social care professionals were positive about the home. The site visit comprised of a full inspection of the premises, which included some service users private accommodation. The care records of four service users were looked, which included service users assessments, care plans and medication records. Staff rotas and health and safety documentation were inspected Time was spent observing activity in the home and interaction between service users and staff, talking and listening to service users, friends and relatives visiting the home. Time was also spent talking to members of staff following the handover in the afternoon. There was also opportunity to speak with a visiting General Practitioner to the home. The focus of the inspection was a number of key standards, inspecting the case records of service users in detail to establish if they corresponded with service users experiences in the home. The registered manager Jean Rowlinson and the deputy manager were both available throughout the day. There were no requirements outstanding from previous inspections. Requirements were made regarding the environment, health and safety matters and care planning. The last unannounced inspection was carried out on the 7 February 2006. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The security of the building requires revising with staff being more vigilant as to who is in the building. This will ensure that service users are protected. Service users daily records require being more specific in detail when there are concerns about the health of a service user. Records must be clear as to how staff manage and meet people’s health care needs especially where there have been concerns raised in service users care plans by other health/care professionals. The carpet outside the office and main kitchen must be cleaned or replaced and the patio doors in the main lounge must be secured back safely, without putting service users at risk. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 7 The Commission For Social Care Inspection Reports are available for staff in the main office, however in discussions held with the registered manager it was agreed that it would be better for staff if a copy was displayed in the staff room. They would then have access to the report without having to come and ask to see it. 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. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Service users are given information and are assessed so that they able to make an informed choice about moving into the home. EVIDENCE: Service users confirmed that they were provided with information about the home before moving in and they had the opportunity to look round the home before making a choice. The manager confirmed that a service user guide is sent to all service users/relatives when making an enquiry about the home. One service user also confirmed that staff from the home visited them to make sure the home could meet their needs and carried out an assessment. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 10 Pre-admission assessments are in place and held on service users individual files and a care need assessment from local authorities were also in place where necessary. There have been no amendments made to the Statement of Purpose since the last inspection. The home does not provide intermediate care. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 was good. This judgement has been made using available evidence including a visit to this service. The care provided to service users was good, however not all identified needs are translated into individual plans of care. EVIDENCE: The service users appeared well cared for and some made comments about the care they received. One service user said that they were “you will not find faults here anyone who complains here are hard to please as its lovely here” and another said “ I have recently been ill and the staff have all been wonderful”. Another service user said, “they’re a grand lot here and staff bend over backwards for you”. Evidence showed that not all identified needs that were assessed are recognised by care planning. The case records of four service users were looked at. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 12 All four care records had detailed risk assessments including reducing risks of falls. Care plans were comprehensive in detail about service users needs and how they were to be met by care staff. However daily records for one service user, who requires regular monitoring regarding their weight was not been recorded consistently. Daily records were not detailed sufficiently enough to be able to monitor the service users health as required and to ensure that the home was continuing to meet that persons needs. This was discussed and agreed with the registered manager that staff need to be specific in detail when recording how they meet service users needs especially where there could be possible concerns regarding their health. The case records of four service users were looked at. All four care records had detailed risk assessments including reducing risks of falls. Referrals and visits by GPs and other health and social care professionals were recorded. A visiting GP to the home was spoken to and said, “ the home is excellent, staff are very caring and competent and know what they are doing and residents are well looked after”. Service users confirmed that appointments are made for the dentist and optician. The home had a call bell system and service users confirmed that call bell requests were attended to quickly. The home now has a new medical room specifically designated for the storage of all medication for the home. The door to the medical room is kept locked and the senior carer on duty has responsibility for the key. The medication system and facilities were inspected. The home operates a monitored dosage system. Proper procedures were in place for the administration and storage of medication and a random check of medication supplies tallied with records. The medication administration records were up to date. Service users and one visitor were spoken to about how they experienced the way in which service users are treated at the home. All said that whether they are service users or visitors they are treated with respect and service users privacy is upheld. One visitor said that “staff always take time to address things and you are always made to feel welcome and the person I visit enjoys living at Borrage House”. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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. Daily routines enable service users to have control over their lives. Activities in the home are good and meets the social needs of people living in the home. EVIDENCE: Throughout the day from observations made and the discussions held with service users Borrage House does arrange regular activities in the home for people to attend if they so wish. One visitor said that the home employs an activities organiser “ who tries to motivate people”. On the previous evening the home had arranged a brass band to play for service users, relatives and visitors to the home. This was held outside on the patio area. In discussions held with service users all enjoyed this event. One service user said that the band played songs from World War Two to the Beatles and Gilbert and Sullivan, “ a real mixture”. Another service user said they had enjoyed the event “ I had a snowball to drink and there was plenty of food and drink and even the band was fed”. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 14 The hairdresser visits the home regularly as a number of service users were having their hair done during the day. The home ensures that religious services are held for those service users who wish to attend, as there were notices of the next dates of services displayed around on the notice boards. There is an activities programme on display in the home. Service users all confirmed that they are able to get up and go to bed as they wish and that visitors are able to visit them at anytime. On the whole service users said that the food at the home was very good. There is a choice at each mealtime one service user said “ the food is good here, plenty of it and plenty of drinks”. Another service user said that the food was a “little boring” and one comment from the survey said “meals have become monotonous, mainly teas”. This was fed back to the registered manager who said that the cook had only recently changed the menu. Staff had recently completed the Dinning with Dignity course, which looks at how a home can improve meals for service users. This also involves things like showing service users each mealtime the choice of food available so that service users can actually choose what they want to eat. The staff were also made aware of such thing as making a difference for people who are partially sighted by the provision of suitably coloured plates not white plates so people can see the outline of the food they are eating. There was one concern raised from the surveys received. This was regarding service users being able to wander in and out of a large working kitchen when lunch was being cooked. However on the day of the site visit there was a notice on display requesting service users/relatives and visitors to refrain from entering the kitchen, but to ask kitchen staff for assistance which they would deal with as promptly as possible. This issue was raised with the registered manager who said that service users and relatives had been going into the main kitchen for drinks and this had now been stopped, as this has health and safety implications and would be working against advice from environmental health. The home does have a small service users kitchen near to the large lounge for people to use. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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. Service users are confident that their complaints and concerns will be dealt with and are safe living in the home. EVIDENCE: The home has a comprehensive complaints procedure in place which is made available to service users as it is displayed on the notice board. The home records all complaints they receive. No complaints have been made either to the home or the Commission For Social Care Inspection. Service users said that they were aware of how to raise any concerns. They said they would approach care staff or the homes management team and they were confident that they would put things right. Comprehensive policies and procedures on the protection of vulnerable adults were seen including the local multi-agency agreement. Twelve staff have recently undertaken a course on the protection of vulnerable adults, this was also confirmed by staff. In discussion they all appeared confident in the action to be taken should abuse be suspected or alleged. Borrage House DS0000007958.V302836.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): 19,20,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, clean and comfortable environment that is suitable for their needs. EVIDENCE: On the day of the site visit the home was warm, bright and clean. There were no offensive odours in any areas of the home. Bedrooms and communal areas were clean and tidy and furniture and fittings were well maintained. There was only one area that required attention. The carpet between the office and the main kitchen was badly stained and requires cleaning or replacing. Several service users were able to show the inspector their rooms. Service users rooms had all been personalised with their personal belongings including pieces of furniture. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 17 Assisted bathrooms and toilets were situated near to service users bedrooms and communal areas. One service user said that she did not need much assistance with anything only bathing and her laundry being washed to which she commented, “The laundry lady is very good”. As her washing had only gone to be done that morning and she had it returned the same afternoon. Service users are able to choose where they sat during the day either in the lounge area or their own rooms if they so wished. Service users accommodation is over two floors, which can be accessed by a passenger lift or staircase. There is level access to the home. This meant that any service users who had difficulty with mobility or used a wheelchair had access to all parts of the home. The main lounge has patio doors which both were wedged open. One door was held open with a large piece of wood and the other with a large stone. For anyone with any sight problems would not necessarily see the piece of wood or stone. This is a potential risk to service users and needs to be addressed. A better way of holding back these doors in the summer months must be found. . Borrage House DS0000007958.V302836.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 is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are sufficient in meeting the assessed needs of service users. Service users are protected by the home’s vigorous recruitment procedures. EVIDENCE: The duty rota showed that there is four care staff on duty each morning, afternoon and evening this does not include management hours. There is the registered manager, one deputy and one senior. There is also one administrator, four domestic and two kitchen staff. At night there are two waking night staff with one senior that is on call. Service users said that they felt that their care needs were being met and that staff are easily accessible. The home had a call bell system and service users said that the call bell requests were always attended to quickly. The staff records of three staff including a recently appointed member of staff were looked at. All records showed completed application forms, two written references, CRB (Criminal Record Bureau) checks had been obtained. A POVA first check had also been carried out. Five staff hold NVQ Level 2 and 6 staff are completing NVQ Level 2. Training such as Fire safety, Health and Safety, COSHH, Back Care, Purpose, Mission Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 19 and Values, Dinning with Dignity are some of the training that has been completed by staff. The home holds a training file for staff. This identifies what training staff has completed and what training is needed. Further training to be arranged for staff varies from first aid, dementia and challenging behaviour. Borrage House DS0000007958.V302836.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 service users and staff benefit from the ethos and leadership of the management team who safeguard service users interests and ensure their safety. EVIDENCE: Information provided from the pre-inspection questionnaire and the examination of selected health and safety documents show that regular checks to hot water delivery, electricity and gas and fire safety equipment are regularly undertaken. Fire Training for staff was last held on 2/6/06. The ethos of the home is open and positive. Service users, relatives/visitors and health and social care professionals all commented highly about the home. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 21 Service users finances were not checked at this site visit, however information supplied by the pre-inspection questionnaire and historical evidence from previous reports gives evidence that service users financial interests are safeguarded. Staff confirmed that staff supervision and annual appraisals is carried out. Quality Assurance systems are in place and the home is audited regularly by the organisation. One of the organisations area managers carries out regular monthly visits to the home and a report is completed and a copy sent to the Commission for Social Care Inspection. Internal surveys are to be carried out and distributed to all service users. However an independent company on behalf of the organisation has carried out a survey in the home. A report into the findings and outcomes has been completed. One concern was raised via the surveys received. This was regarding the security of the building, as the comment made was “people are able to enter the building with no staff in sight”. On the day of the site visit the inspector verified this. In discussions held with the registered manager it was made clear that staff should at all times be vigilant as anyone is able to walk into the home. This in effect puts service users at risk. The home was requested to revise its security. Borrage House DS0000007958.V302836.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 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 1 3 X X 3 3 3 1 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 1 Borrage House DS0000007958.V302836.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 OP7 Regulation 17(1) Requirement Timescale for action 06/10/06 2 OP19 13(4) 3 OP26 23(2) 4 OP38 12(1) The registered provider must ensure that daily records are concise and are specific in detail when monitoring the health care needs of service users. The registered provider must 06/10/06 ensure that when the patio doors are fastened back they are done so without putting service users at risk. The registered person must 06/10/06 ensure that the carpet between the office and main kitchen is either cleaned or replaced. The registered person must 06/10/06 revise the homes security measures to ensure that service users are protected at all times. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 24 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 OP28 Good Practice Recommendations The provider should endeavour to have 50 of care staff trained to NVQ Level 2 standard. Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Borrage House DS0000007958.V302836.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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