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Inspection on 16/06/05 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 16th June 2005.

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

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 environment was clean and odour free. The refurbished area of the home (Cardinal Court and the Miriam Unit) has been decorated and furnished to a high specification. Once the second phase of the building is complete the quality of Regency Court will change dramatically. Service users were complimentary about the support from staff that they received.

What has improved since the last inspection?

The environment has improved and in Regency Court some interim measures have been implemented to ensure that the quality of surroundings does not deteriorate. A high proportion of previously made requirements and recommendations have been met and service users needs are more accurately reflected in their care plans.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Borehamwood Care Village 10-20 Cardinal Avenue Borehamwood Hertfordshire WD6 1EP Lead Inspector Angela Dalton Unannounced 16 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 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 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 953 7084 Aspen Village Limited Nancy Rasool CRH Care Home with Nursing 95 Category(ies) of OP-89, PD-6 registration, with number of places Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15 September 2004 Brief Description of the Service: Borehamwood Care Village is undergoing refurbishment and building work and has completed the first phase of development. The home is now viewed as a whole incorporating three separate units. The completion of the second phase will physically join the two separate buildings and this is scheduled for January 2006. The new provision for young physically disabled service users who require nursing care is complete and will accept admissions in the near future. Currently, the main kitchen, laundry and staff rooms are on the second floor. These areas will be redesigned and improved as part of the refurbishment. The home provides accommodation and care for its elderly service users in a safe and secure environment. Cardinal Court also houses 16 Closed Care Apartments (Sheltered Accommodation). 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 which is being expanded and landscaped. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by three inspectors on 16th June 2005. The inspection commenced at 10.20 am and concluded at 5pm but two inspectors left prior to this. A concerted effort has been made to meet the requirements made at earlier inspections. What the service does well: 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. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Service users are equipped with sufficient information to ensure that they are able to make an informed choice about the home. EVIDENCE: The home manager has regularly updated the Statement of Purpose to ensure that the document accurately reflects the services available. Another review is due to reflect the new provision for younger service users with a physical disability and associated nursing needs. As service users are changing rooms and have requested to move to the refurbished area new contracts will be issued. A qualified member of staff conducts assessments. The home can access other professionals to assist where an individual has specific needs. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10,11 Service users are vulnerable because of incomplete medication and care records. EVIDENCE: The information contained within care plans has improved since the previous inspection. It is recommended that risk assessments are reviewed to ensure that the identified risk and method of management is current. The content of care plans was fairly comprehensive but there are some areas that still need to be addressed. Sensory needs are not addressed and description of medical needs and management should be expanded e.g. for service users with epilepsy. Medication recording requires attention as there are gaps which do not evidence if medication has been administered or refused. Medication amounts also need to be carried forward onto medication record sheets to enable amounts to be accurately checked. The majority of service users were complimentary about the staff who supported them. Staff should be mindful that some service users find it difficult to understand them if they are from overseas. Inspectors observed some positive interaction and staff who had a gentle manner. Other staff were observe to wheel a service user into a lounge, get them a drink without any interaction. This was also observed whilst a service user was being assisted with a meal. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 9 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 The home meets service users expectations. Service users are not always aware of menu choices. EVIDENCE: Relatives were complimentary about service users’ care. A record of activities is kept and those available are advertised throughout the home. The home has links with local churches that conduct services within the home. Lunch was hot and tasty. Although a menu is available some service users were not aware of the options prior to the meal. Consideration should be paid to how it can be displayed in a format that service users can see daily choices. The issue of compromised dining space will be met following the refurbishment. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17,18 Service users have access to a complaints procedure. EVIDENCE: Staff were aware of the policy to follow if they had concerns about a service user. An updated Service Users’ Guide is to be distributed and this informs service users how to complain and raise any concerns that they may have. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 11 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The environment is improving to meet service users needs. EVIDENCE: Furnishings and décor is being replaced and updated as part of the refurbishment process. The service users are enjoying the new facilities that have been created in the refurbished part of the building and the conservatory is well utilised. Blinds are on order to ensure that the environment is comfortable in hotter weather. Drinks were available and each area has its own fridge to enable staff to meet individual needs rather than travelling to the main kitchen. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 12 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) It is not possible to verify that comprehensive recruitment checks are conducted upon all staff. Staff would benefit from additional training. EVIDENCE: The manager explained that qualified nurse numbers were usually higher but due to two open days they were lower. The rota bore this fact out. The majority of staff files checked were complete but a requirement has been made to ensure that CRB checks are evidenced and that all staff have two references on file. Training is available to ensure that staff are updated regarding first aid, moving and handling and other core subjects. A recommendation stands to offer staff training relating to specific medical needs such as diabetes and epilepsy. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 13 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37,38 The home is run in the best interests of service users. EVIDENCE: The manager has overseen a complex change within the home. Service users spoke highly of how approachable the management team were within the home and were comfortable in raising any concerns that they have. Staff supervision occurs and the manager is taking steps to streamline this process. A move of staff within the home has created a senior nurse vacancy. The appointment of an additional sister or charge nurse will assist in regular supervisions being achieved. As the attachment for the laundry air conditioning unit has been borrowed it is recommended that an alternative be found. This will prevent the laundry temperature from becoming too high to work in. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 14 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 2 Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 15 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12(1)(a) Requirement Timescale for action 31/07/05 2. OP9 13(2) 3. OP29 19(1)(b) Schedule 2 17(2) Schedule 4 Risk assessments must be reviewed to ensure appripriateness and accuracy. Care plans must adequately inform staff how an identified need is managed e.g. sensory impairment, epilepsy 30/06/05 Medication dates of opening must be recorded. Amounts of medication must be carried forward and recorded on Medication Administration Record Sheets. THIS REQUIREMENT WAS MADE AT THE PREVIOUS INSPECTION. Gaps must not appear for regualrly prescribed medication and if ommitted a reason be recorded. The home manager must 30/06/05 evidence that all staff have an appropriate Criminal Record Bureau check and two references kept on the premises. Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 16 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 OP10 Good Practice Recommendations Staff should be mindful that service users are spoken to in a way in which they understand and are informed about what is happening e.g wheeled to a different room, assisted with a meal etc. Menus should be better displayed to enable service users to make an informed choice about their meals. The laundry temperature should be at a comfortable temperature to work in. 2. 3. OP15 OP38 Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 17 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City, Herts AL7 3BQ 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 Borehamwood Care Village I52 s38639 Borehamwood Care village v233356 160605 Stage 4.doc Version 1.30 Page 18 - 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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