CARE HOMES FOR OLDER PEOPLE
Borehamwood Care Village 10-20 Cardinal Avenue Borehamwood Hertfordshire WD6 1EP Lead Inspector
Mrs Alison Butler Unannounced Inspection 15th May 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.V341316.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.V341316.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.V341316.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). 13th March 2007 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 a 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 people who use the service 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). Information regarding the service is available in the Statement of Purpose and Service User Guide, these and a copy of the most recent CSCI inspection report can be freely obtained from the manager. Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors carried out this key inspection. Due to the fact it has only been a short time since the last inspection not all areas were inspected on the site visit, but where the information has remained the same this has been brought forward into this report. Whilst the overall judgement of the service is adequate it is recognised a great deal of work has been carried out to ensure those who use the service have a good quality of life and they are able to maintain the standards in place. A large amount of time was spent observing and talking with the people who use the service. Care records were also examined. What the service does well:
There is a good management structure in place, this has proved to be an asset to the home as each individual has their own area of responsibility and staff are clear who is responsible for what area and know who and where to go with any concerns. Care plans have good quality of information recorded giving guidance to staff on meeting individual needs. A key worker system is in place and staff are fully aware of their responsibilities. Activities for those using the service have much improved and individuals are consulted on what they would like to do, various activities are carried out with a weekly programme and all staff are responsible for joining in and running the sessions. The atmosphere is calm and relaxed. The environment is well maintained. There is a good quality assurance system in place and this is hoped will ensure that the managament continue to look at improvements that can be made within the home to provide a good quality service to all who live at Borehamwood Care Village. A training programme is in place and updated as and when required to ensure staff have the skills and competency to carry out their roles effectively and to the benefit of those living at the home. Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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.V341316.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.V341316.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): 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: This area was inspected on 13th March 07 and therefore the information has been carried forward. 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. Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 9 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.V341316.R01.S.doc Version 5.2 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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. The quality of information recorded is good. However, not all residents receive a good quality of care and are not all supported by knowledgeable and experienced staff. EVIDENCE: The information recorded is of a good quality giving guidance to staff on the use of bed rails, wheelchairs and other equipment. There is a good procedure on the reporting of faults and these are usually rectified fairly quickly to ensure that individuals’ needs are met appropriately. The key worker system that has been re-introduced appears to be working well and staff are fully aware of their responsibilities. The manager and his team have dealt with the issue regarding confidentiality and that staff are clear that they must check information that is placed on the files by other professionals.
Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 11 Residents spoken to still continue to be complimentary about the care that is provided and how much this has improved over the last six months since the new management team has been employed. Policies and procedures for the safe handling of medicines are in place. The manager responded to the last inspection report stating that issues regarding the medication had been addressed and therefore this area was not inspected during this inspection. This area has been judged as adequate and will continue to be monitored to ensure they are able to maintain the standard over the coming months, to ensure good outcomes for those who use the service. Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Contact with family and friends are encouraged. Autonomy and choice is not always promoted within the home. Residents receive a wholesome and appealing well balanced diet. EVIDENCE: The areas that support those who have dementia have improved greatly. This has been done by looking at the individual needs and putting similar needs together and reducing the total number of people on each unit and looking at the training provided for staff. The atmosphere on these units was a lot calmer and appeared less busy. Staffing provided is appropriate to meet individual needs. One member of staff has obviously not understood the needs of those who are less able to communicate, as they failed to speak with them about what was happening when providing care and disturbing them when they were sleeping in the chair. When they were supporting them to walk they outpaced the person by taking their hand and walking ahead of them with arms outstretched. They also did not interact with them except when completing a task. Further training is
Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 13 needed or the managers should consider a move to where people are more able to express their needs. The activity team are now going onto the different units and starting an activity, staff then continues with this activity. This has helped in ensuring that everyone has responsibility in meeting the needs of the individuals, it is not just the activity teams responsibility. The level of volume has been reduced on the units and a folder has been produced with large pictures to show what music is available, this will be changed to ensure different choices are offered based on an individuals history. Staff were seen using the folder to ask what music they would like to listen to. There is a residents committee with a group of residents who represent each floor/unit who were voted by the residents on each floor. The management team are able to attend the meeting by invitation only. On the day of the inspection the manager had been invited to attend as they had items which they wished to put to him. The inspector asked at the beginning of the meeting if they minded if she could join them and talk a little about their lives at Borehamwood Care Village. They were complimentary about the care and how much things have improved over the last 6 months and they are getting their issues dealt with. They have also agreed to complete some questionnaires prepared by the Commission and have offered to assist those less able. The inspector will have the questionnaires sent to them and each will have an envelope so that they can be retuned confidentially which will provide information for the next inspection. The inspector would like to thank those people for their time and assistance during the inspection process. Minutes of the meeting are taken and are available to all residents There were numerous posters around the building inviting residents to various events for example Karaoke with Richard and a 50’s and 60’s production - this event goes down very well and is very much enjoyed by most of those spoken to. There is a monthly gents club and ladies club, this is where the various groups can get together play games and have a drink of beer, wine, tea or coffee. An activity programme is in place that is done on a week-by-week basis. Those spoken to were complimentary about the food and stated that the residents meeting addresses any issues about food and if necessary the chef will be invited to attend and listen to what the problems are. Families and friends are able to visits the home at any reasonable time and are offered hospitality they are also able to help themselves from the machine in the reception area to the home. Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 14 There is a monthly newsletter, which includes articles from those people who use the service; this also informs them what events are coming up and feedback of events that have taken place. Feedback from questionnaires that were sent out by the Commission stated, “The staff are very well mannered, friendly and clearly work hard to keep the village running ship shape”. Other comments were “ more encouragement should be provided to help her lead a more full life” “ good provision of activities and entertainment” Borehamwood Care Village DS0000038639.V341316.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. 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: Complaints have been dealt with appropriately and are well documented. The outstanding complaint is still to be actioned and the manager is still trying to arrange with the family to meet with them. He will continue to pursue this or at least try to put a close on the complaint as it relates to issues before he took over as manager and would like to ensure a positive outcome for the people involved. Borehamwood Care Village DS0000038639.V341316.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. 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: The number of beds has been reduced within the two-dementia units and by changing the use of some of the rooms which now contain items such as rummage boxes, books and items from years gone by individuals can have time on their own in a more relaxed way. The process of converting the flats within the home into large bedrooms to accommodate residents who have a physical disability and need moving and handling equipment has started. A sluice room is being converted into a further bathroom and 6 new style baths are being fitted to replace the baths already in place, these will better meet the needs of the residents.
Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 17 The 1st floor kitchenette is almost completed and will offer a self-service coffee bar that can be used by residents, and their families and staff free of charge. There is a large physiotherapy unit available on the first floor that has greatly benefited the people who use the service. There has been new washing machines purchased and this has provided a more efficient laundry service at Borehamwood Care Village. There is an activities room, which provides Internet access, and a variety of craft materials are also available. There are security systems in place with the use of CCTV in corridors and lounges; this assists in monitoring the safety of both the residents and the staff. Keypads are in place at appropriate doors for the protection of those who may be at risk if they were able to walk around the whole building freely. The home was cleaned to a high standard and provides a well lit, airy and well maintained environment that was free from any mal odours on the day of the inspection except in one of the dementia units where the staff were continuing to address the issue appropriately. Questionnaire and visitor comments gathered for the inspection included “the building and rooms are marvellous” “there has been great improvement in the décor of the building” Borehamwood Care Village DS0000038639.V341316.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. 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: As the files were examined at the last inspection and showed that all the required information had been obtained prior to staff commencing employment they were not examined at this inspection. The recruitment drive has proved successful and has provided those using the service with a more consistent approach, as there has been no need to use agency staff. The training matrix showed that all the training provided is recorded and updated as appropriate. Additional training has taken place in meeting the needs of those who have dementia. There was evidence that whilst the training had been carried out it may have been of a too high a standard for some staff, as some spoken to felt that they did not necessarily understand all that was taught. This had already been highlighted by the management team and was being addressed, as future training has been booked. The management have reduced the number of adaptation nurses taken within the service to ensure that residents receive a consistent staff team. Those who
Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 19 are taken on for adaptation now have to take an English test and reach a certain grade as this helps when nurses need to communicate with the residents. In the past when there was a large number of overseas staff that had English as a second language, communication was very difficult for the residents and this was highlighted as an issue. This is another area, which is to 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. Comments received from the questionnaires included “ staff are extremely kind and considerate” “staff are very well mannered and friendly” “ feels safe and happy living at the village” Borehamwood Care Village DS0000038639.V341316.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. 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 manager has yet to apply to be registered. This has been delayed as paperwork required for the application has been taking a significant time and it is hoped that the manager has been able to resolve this and the completed application can be submitted to the Commission very shortly. The new management structure that has been put in place appears to be working extremely well with each senior person have their own areas of
Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 21 responsibility. 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 running of the home, the manager was invited to attend the meeting on the day of the inspection. A quality assurance programme has been purchased and put into place, this provides an audit tool to review the service provided and ensure that the service continues to meet the needs of those who live at the home. Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Borehamwood Care Village DS0000038639.V341316.R01.S.doc Version 5.2 Page 23 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 OP31 Regulation 8 Requirement The proprietor must submit an application to register a manager with Commission for Social Care Inspection. (This requirement
remains unmet from the previous inspection 04/03/07 a new timescale has been made). Timescale for action 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Borehamwood Care Village DS0000038639.V341316.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
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