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Inspection on 13/03/07 for Forest Care Village Elstree & Borehamwood

Also see our care home review for Forest Care Village Elstree & Borehamwood for more information

This inspection was carried out on 13th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The atmosphere on entering the home was calm and welcoming. The new management group have examined the recruitment process and have reduced the number of adaptation nurses needed. The home was clean and well maintained. Good fire procedures are in place and these proved to work extremely well during a fire at the home in December 2006. The residents were complimentary about the food provided.

What has improved since the last inspection?

There have been a number of improvements since the last key inspection in May 2006. The environment has improved with redecoration carried out in consultation with the residents. Information recorded in the care plans provides details of the action required by staff to assist the residents in meeting their needs. The concept of a key worker role has been introduced in which an individual staff member is assigned to a resident to ensure their records and care plans are kept up to date and reviewed on a monthly basis. Residents felt their care has improved over the last six months and their needs are responded to more swiftly. Medication procedures have improved in recording, storage and disposal of medicines. More activities are on offer especially for the more able residents. A resident`s committee has been set up and run by the residents for the residents. Complaints appear to be being handled within the timescales laid down in the policy and the information, action and outcome being recorded. Staff appear clear on the action to follow in the event of an allegation of abuse becoming known to them. An increase in staffing levels now provides a more consistent approach for the residents with little reliance on agency staff. The activities on offer have increased following the employment of three activity co-ordinators. A new management structure has been introduced and staff are clear about roles and responsibilities within the structure. The new managers have looked at the needs of some younger residents and have moved them to the top floor with staff who don`t wear uniforms and are called support workers rather than nurses.

What the care home could do better:

Training for staff in dealing with the less able residents and those who suffer from dementia is required to enable staff to respect and communicate with those residents more appropriately. The number of residents and the various abilities should be reviewed, as a small area within the unit that cared for those who suffer from dementia was seen to be overcrowded. Moving and handling of residents should be addressed to overcome the poor practice that was observed. Staff should remember to include the date of any handwritten information on the medication, administration and recording sheet. Advertising activities should be reviewed and possibly look at producing it in a large pictorial format for the less able residents.

CARE HOMES FOR OLDER PEOPLE Borehamwood Care Village 10-20 Cardinal Avenue Borehamwood Hertfordshire WD6 1EP Lead Inspector Mrs Alison Butler Unannounced Inspection 13th March 2007 10:00 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 Borehamwood Care Village DS0000038639.V335162.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. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Borehamwood Care Village Address 10-20 Cardinal Avenue Borehamwood Hertfordshire WD6 1EP 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) 0208 236 2000 0208 9537084 Aspen Village Limited Manager post vacant Care Home 178 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (178), of places Physical disability (20), Terminally ill (5), Terminally ill over 65 years of age (5) Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The terminal illness category is not to exceed in 5 beds in total for both TI and TI (E). 25th October 2006 Date of last inspection Brief Description of the Service: Borehamwood Care Village has recently undergone refurbishment and building work and has expanded provision to include younger people with physical disability and a dementia care unit, as well as older people who may need nursing care. The complex is situated a short level walk from the main shopping area of Borehamwood and accessible from the nearby main railway station. There is ample parking within the complex and service users have access to a small garden to the rear of the property. The fees for the service range from £513.00-1500.00 per week (these were correct as of 13/03/07). Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Five inspectors conducted this inspection. The report has been written following a total of four visits that have been undertaken since the last key inspection in May 2006 and information that has been known to the Commission. One inspector spent two hours of the site visit observing the care being given to a small group of residents using a short observational framework inspection tool. Time was spent on each of the units within the home speaking with staff, residents and visitors to the home. Care records were also examined. What the service does well: What has improved since the last inspection? There have been a number of improvements since the last key inspection in May 2006. The environment has improved with redecoration carried out in consultation with the residents. Information recorded in the care plans provides details of the action required by staff to assist the residents in meeting their needs. The concept of a key worker role has been introduced in which an individual staff member is assigned to a resident to ensure their records and care plans are kept up to date and reviewed on a monthly basis. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 6 Residents felt their care has improved over the last six months and their needs are responded to more swiftly. Medication procedures have improved in recording, storage and disposal of medicines. More activities are on offer especially for the more able residents. A resident’s committee has been set up and run by the residents for the residents. Complaints appear to be being handled within the timescales laid down in the policy and the information, action and outcome being recorded. Staff appear clear on the action to follow in the event of an allegation of abuse becoming known to them. An increase in staffing levels now provides a more consistent approach for the residents with little reliance on agency staff. The activities on offer have increased following the employment of three activity co-ordinators. A new management structure has been introduced and staff are clear about roles and responsibilities within the structure. The new managers have looked at the needs of some younger residents and have moved them to the top floor with staff who don’t wear uniforms and are called support workers rather than nurses. 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. The summary of this inspection report can be made available in other formats on request. Borehamwood Care Village DS0000038639.V335162.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 Borehamwood Care Village DS0000038639.V335162.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 & 3 Standard 6 is not applicable to Borehamwood Care Village. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to residents and their representatives to enable them to make an informed choice. Assessments are carried out on all residents prior to a place being offered or taken up. EVIDENCE: A comprehensive Statement of Purpose and Service User Guide is available to all prospective residents and their representatives and this includes the care of residents who suffer from dementia. Pre- admission assessments are carried out prior to admission and this forms the basis of the care plan. Each resident is provided with the terms and conditions of admission etc. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Quality of information recorded is good. Not all residents receive a good quality of care and are not all supported by knowledgeable and experienced staff. EVIDENCE: There has been a great improvement in the information recorded in the care plans. There is guidance to staff on ensuring bed rails, wheelchairs and other equipment is well maintained and there are instructions on how to report any faults immediately. Any medical intervention and outcome is recorded on the doctors visit sheet. The key worker system has been reintroduced, which will give residents an allocated person who is responsible for ensuring care plans and other information is up to date. At the start of each shift a member of staff is allocated a number of residents who they responsible for during the shift, ensuring their care needs are met and the daily records are up to date. A monthly review takes place, which Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 10 includes input from the residents. On one file there was an issue regarding confidentiality, where sensitive information regarding another resident was detailed within some review notes written by a social worker. The information should have been erased before being placed with the individuals’ file; the manager was to address this as a matter of urgency. Residents felt that the care provided has much improved over the last six months. For example, one resident felt that they had to wait to have their toileting needs met as they were fully dependent on staff but this is not a problem any more and the response is quick. “Staff are kind and helpful was another comment. Staff were observed interacting well with the residents, there was gentle banter and staff were seen to gently encouraging residents appropriately. (See section on daily life and social activities for further information where less able residents are not treated with the dignity and respect they deserve at all times). Examination of the medication showed that they were well kept on the whole, with the exception that dates should be added when handwritten information is put on the medication administration sheet. Room temperatures are taken and recorded and remain within safe limits for the storage of medication. Policies and procedures are in place for the safe handling of medicines. Whilst this area has shown to be greatly improved since the last key inspection in May 2006, the outcome has been judged as adequate and will be monitored to ensure that the service is able to maintain the standard over the coming months. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Contact with family and friends is encouraged. Autonomy and choice is not always promoted within the home. Residents receive a wholesome and appealing well balanced diet. EVIDENCE: Three activity co-ordinators have now been employed and they have been assigned a room where residents can come and take part in craft activities. They also have access to the Internet. On the day of the inspection, a resident was being supported to search the net for information about Borehamwood. They found a picture that they were going to use to paint a mural on the wall of the activity room. A group of residents were playing skittles in the main reception area. Once the activity had been finished, the equipment was not put away safely and this could cause a health and safety issue to residents, visitors and staff. Staff should be reminded that equipment must be moved and put away safely once an activity is over. There were a variety of posters around the building inviting residents to various events (for example Karaoke with Richard and a 50’s and 60’s production). There is also a monthly gents Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 12 club and ladies club, where the various groups can get together, play games and have a drink of beer, wine, tea or coffee. A week-by-week activity programme is in place that could be produced in a bigger format and with the use of pictures to enable more residents to access the information independently. There is a residents’ committee s a group of residents who represent each floor/unit, the members were voted by the residents on each floor, the management team are able to attend the meeting by invitation only, (and this may happen when residents would like some of their questions answered etc.). A resident’s meeting took place during the afternoon of the inspection; minutes of the meeting are taken and are available to all residents. The activity co-ordinator is responsible for putting together the homes newsletter and residents are also encouraged to input into it. In the unit caring for residents who suffer from dementia it was observed that staff entered the area without any form of greeting to the residents. The ethos of the home must change to ensure the residents who live here are respected. The inspector saw staff walk into the sitting room without acknowledging the residents in any way. A maintenance man walked through the sitting room on a number of occasions without respecting the fact that he was in somebodys home. There was a CD player in the sitting area of the room. This was being played at a very loud volume which, is assumed, was to enable all residents in the area to hear it. The staff failed to ask the residents if the volume was acceptable. One resident appeared to be suffering from this loud noise as they had their face in their hands. However, no member of staff appeared to acknowledge them. The inspector stood beside the equipment for a time and found it to be uncomfortably loud. When mentioned to a member of staff they reduced the volume and when another member of staff entered the room they again increased the volume without checking with the residents if this was what they wanted. Staff were also seen changing the music without checking with the residents first. One member of staff threw open double doors into the garden, again without checking with residents. Frail residents who were by the door were unable to say that it was cold and it was only when the cold air reached the more vocal residents that one of them was able to ask for the doors to be closed. Staff must respect the dignity of the residents and involve them in what is happening in their home. Staff appeared to be keen to engage the residents in activities. This suited some residents very well but others, due to their frailty were left out. Again staff appeared to be unaware of this. The main aim appeared to be to have activities going on. The unit was geared to those who were more able and those who were unable to join in were often ignored. Activities on the day included golfing mats. The area was unfortunately too small to ensure that these activities were carried out safely and, because of the confined area, residents were shuffling over these objects and were putting themselves at risk of falling. Staff on duty appeared to be unaware that this could cause a potential problem to the residents. There was little evidence in the outcomes for the residents that staff engaged in the care of people who have dementia had received appropriate training. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 13 Staff appeared to be very keen to care for residents but lacked direction. When the activities co-ordinator was organising activities it appeared that they felt unable to take part in these activities and stood back and watched. A resident needed to be assisted and a hoist was being used. Staff did not speak with the resident and tell them what was happening. Another example of poor moving and handling was observed when a resident who had slipped in her chair was hoiked back up in their chair by two members of staff. There were 19 residents being cared for in one large room. This room was subdivided into a dining area and a sitting area. The most vulnerable residents were in the sitting area. It is felt that the area is not suitable able to meet the needs of this number of residents and the range of abilities and support needs. It is felt that more possessions in resident’s bedrooms could be beneficial and may provide them with comfort at times when they appear to be unhappy or distressed. A hairdresser visits the home 2-3 times a week and residents are able to book an appointment. Residents were on the whole complimentary about the food provided, although some felt that they would like to have more steamed puddings both savoury and sweet. A comment received was “too much modern stuff and would like more of the old favourites”. There has been discussion held with the residents about the menu and then new kitchen staff to try to offer them the food they would like. The area of food is also addressed within the residents meeting. Family and friends are able to visit the home at any reasonable time and are offered hospitality. Borehamwood Care Village DS0000038639.V335162.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to protect the residents from abuse and ensure complaints are dealt with appropriately. EVIDENCE: There have been a number of complaints received by the service since the last key inspection in May 2006. The manager, who has been in post since October 2006, has been following up complaints that were received at the home prior to his arrival as well as dealing with subsequent complaints. These have been recorded appropriately and any outcomes recorded. There is one compliant that is currently being dealt with and the manager is planning to meet the complainants to address the issues raised. Hopefully, this will lead to a positive outcome. Staff have received training in adult protection (Safeguarding Adults) and appear to understand their responsibilities in reporting any issues that are raised with them. Whilst this area has shown to be greatly improved since the last key inspection in May 2006, the outcome has been judged as adequate and will be monitored to ensure consistency. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and well maintained. Regular checks are carried out on services and equipment. EVIDENCE: There has been a great deal of alteration and redecoration over the past six months. Further work is still to be done and a plan is in place. The home suffered from a fire in December 2006 and the affected room is in the process of being decorated. (See management and administration section for details of the fire). Flats in the home are being converted in to large bedrooms that will accommodate residents who have a physical disability and need assistance from moving and handling equipment. A sluice room is being converted into an additional bathroom and six new-style baths are being fitted to replace the baths already in place. These will better meet the needs of the residents. The Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 16 first floor kitchenette is being replaced and made into a self-service coffee bar which can be used by residents, their families and staff free of charge. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Robust procedures are in place to ensure that residents are protected at all times. The numbers and deployment of staff appear to meet the needs of the residents. EVIDENCE: Examination of the staff files showed that all the required information had been obtained prior to commencing employment. All staff sign to say they have received a copy of the staff handbook. There has been a change in the management team with the employment of the homes manager (Village Director), a clinical general manager who commenced in October 2006, a non-clinical general manager, a clinical nurse manager and a catering manager. There has been a recruitment drive and this has proved beneficial to the residents as the additional staff are providing consistent care. A training matrix is in place and training which has taken place in the last six months has included adult protection, fire, medication, communication, introduction to dementia and moving & handling. There is still a need to increase the knowledge of those who work with residents who suffer from dementia, because observation in the unit showed that staff still were unable to fully communicate with them. (See section on Daily Life and Social Activities). At Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 18 one point there appeared to be staff standing around and not clear about what to do to meet the needs of those who suffer from dementia. The rotas showed that adequate numbers of staff are deployed providing a 1 to 5 ratio. Staff were seen in the other units to be caring and encouraging residents to be as independent as possible or supporting where appropriate. The number of adaptation nurses has been reduced to ensure that residents receive a consistent staff team. New staff undergoing adaptation have to take an English test and reach a certain grade which helps when nurses need to communicate with the residents. This has been an issue in the past as there were a large number of overseas staff making communication very difficult for the residents. This is another area that will be monitored to ensure that it is sustained over the coming year and it is hoped that a good outcome will be reached for the residents. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a good management structure in place. The health, welfare and safety of residents, staff and visitors to the home is protected most of the time. EVIDENCE: The company have employed a manager who has yet to apply to become the registered manager. A number of changes have occurred and a new management structure has been put in place. (See section on Staffing for further details). There has been a great deal of work in putting the new structure in place and this has benefited the residents in providing a more consistent and stable staff team. The residents have also been empowered by the setting up of a residents’ committee in which they can have input into Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 20 running of the home. The managers may only attend these meetings by invitation. Whilst an inspector was observing on the unit that supports residents who suffer from dementia, poor moving and handling practice was observed. An immediate requirement was made for this to be addressed with the staff. There had been a fire in the home in December 2006; a full report was carried out and the staff are to be congratulated on how well they dealt with the situation. The Fire and Rescue Service were also impressed with the fire procedures in place. Fire records were well kept. Accident and incident records were well kept and the Commission has received information under Regulation 37 as appropriate. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 21 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 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 22 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 12(4)(a) Requirement Staff must ensure that the information recorded within residents care plan relates only to them and does not identify other residents to maintain privacy and dignity of all. Staff must be provided with additional training to ensure that they provide the residents with dignity, choice and respect at all times. The registered person must ensure that the home is staffed by suitably qualified and experienced people, especially in the dementia care unit. Staff must also be able to communicate effectively with residents (This requirement remains unmet from the previous inspection 23/05/06) Timescale for action 31/03/07 2 OP10 OP14 12(4) (a) 30/04/07 3 OP12 18(1)(a) 31/05/07 4 OP30 OP38 13(5) Staff must receive additional training in the safe moving and handling of residents. An 13/03/07 immediate requirement was made at the inspection to ensure the safety of residents. 5 OP31 8 The proprietor must submit an application to register a manager with Commission for Social Care DS0000038639.V335162.R01.S.doc 30/04/07 Borehamwood Care Village Version 5.2 Page 23 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 2 Refer to Standard OP16 OP9 Good Practice Recommendations The manager should explore ways to give relatives back trust in complaints being dealt with appropriately. Staff should remember to include a date when completing any handwritten information on the medication, administration and recording sheet. Borehamwood Care Village DS0000038639.V335162.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Borehamwood Care Village DS0000038639.V335162.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. 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