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Inspection on 17/11/05 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 17th November 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

Service users spoke highly of the refurbished home and positively of the staff. Relatives confirmed that they were kept informed of any developments. The environment is steadily improving and work is on schedule for completion early in 2006.

What has improved since the last inspection?

The environment continues to improve. A new chef has joined the kitchen staff team and service users remarked on the high quality of food.

What the care home could do better:

Several requirements have been made as a result of this inspection. Inspectors raised concerns regarding levels of staff and the hours that were being worked as they are in the region of sixty hours and above in most cases. Requirements remain regarding medication and recruitment records which are inadequate. Activities were at a low level on the day of inspection and service users commented about this to inspectors. TV reception remains poor which frustrates service users. Although service users hold the food in high regard the dining experience could be enhanced by the layout of the dining room, as the majority of service users do not currently dine at a table.

CARE HOMES FOR OLDER PEOPLE Borehamwood Care Village 10-20 Cardinal Avenue Borehamwood Hertfordshire WD6 1EP Lead Inspector Angela Dalton Unannounced Inspection 17th November 2005 10:15 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.V264976.R01.S.doc Version 5.0 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.V264976.R01.S.doc Version 5.0 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 Nancy Rasool Care Home 95 Category(ies) of Old age, not falling within any other category registration, with number (89), Physical disability (6) of places Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 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. 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. 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 DS0000038639.V264976.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by two Inspectors between 10.15am and 6.30pm. The home is still undergoing building work but this is less disruptive than it has been in the past although some service users commented on the ongoing noise. Service users appeared well kempt and comfortable. Several requirements were made but the progress identified at the previous inspection has not been maintained. 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 DS0000038639.V264976.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 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 the following standard(s): 3 The home is acting outside of its registration categories. EVIDENCE: The home is registered to provide nursing care to older people and six younger adults with physical disabilities. One service user’s care plan reflected that their primary diagnosis was dementia whilst the younger adults unit is offering a wider admission remittance than their registration category allows. Physical disability does not appear to be service users’ primary need in the majority of cases. Categories of registration are there to provide prospective service users and commissioners guidance on the service users group that the home is able to provide care to. If service users are admitted outside of the registered categories it cannot be that the expertise of the staff and the physical environment are sensitive to the needs of these residents. A requirement has been made. Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 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 the following standard(s): 7,8,10 & 11 Service users may be vulnerable because of incomplete medication and care records. EVIDENCE: Care plans were inspected. There was disparity between the quality and content of in each plan. Service users who had been newly admitted to the home had comprehensive plans whereas other more established plans were lacking information or there were gaps in demonstrating how needs were met. Pressure wound care was being delivered but no care plan was accompanying wound assessments or instructions were given to turn a service user two hourly but no records reflected this. Nutritional plans stated that monitoring was to take place of food and fluid intake and weights recorded weekly. These were not in place. The requirement made at the previous inspection remains unmet. Risk assessments are in place but are still not reflective of changes in risk e.g. pressure care in the case of more established service users. Medication systems require attention as medication could not be reconciled, as accurate records were not kept of variable amounts. ‘Error’ appeared on Medication Administration Record Sheets but it was unclear what the error was and what action has been taken. Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 9 The storage temperature was correct and well controlled. Service users’ dignity could be better observed: The television reception was observed to be poor in parts of the home which was on at the same time as the radio. Staff were consistently busy and at times did not interact with service users e.g. reassurance whilst hoisting was taking place or interaction whilst assisting with meals. Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 10 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 & 15 Service users do not have daily access to activities. Mealtimes are not a positive experience. EVIDENCE: The activities co-ordinator and providers were off sick on the day of inspection. Service users stated that although they enjoyed the activities that there was not something available each day. Some service users reported that they declined to leave their room if there was no reason to. Staffing levels do not afford any additional time to spend with service users. The television reception was observed to be poor in parts of the home which was on at the same time as the radio. Lunch was well received by service users. Choice is provided and service users confirmed that additional options could be requested. Few service users are able to eat at the dining table (this was observed on Regency) due to the provision and layout of the dining rooms. Although this will be further addressed as part of the refurbishment positive steps should be taken to enhance mealtimes. Service users spend a large amount of time sat in the lounge and mealtimes may encourage service users to socialise. 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 DS0000038639.V264976.R01.S.doc Version 5.0 Page 11 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): Not inspected on this occasion. EVIDENCE: Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 12 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): 24 Some bedrooms do not reflect the personality of the service user. EVIDENCE: As the home has recently been refurbished some bedrooms are spartan. Assistance should be provided to ensure that individual rooms are comfortable and meet individual needs. One service user recently moved into the home and needs bookshelves. Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 13 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 & 29 Service users are not protected by comprehensive recruitment checks and safe working practices. EVIDENCE: Some units appeared short of staff with a high service user to staff ratio. Where areas accommodate service users with high levels of need staff are under pressure to meet needs. One unit had been notified that a member of staff was on sick leave but the numbers had not been increased. Staff work internal rotation and this results in a combination of twelve hour shifts worked both during the day and at night, often between sixty and seventy two hours each week. Rest days are recorded as days off. A member of staff who is on a day off after a night will be sleeping and not utilise this as a day off work. This can only affect the quality of care delivered. Laundry staff appear overwhelmed as there has been an increase in work but until the move to the new premises takes place provision will remain inadequate. An increase of staff would ensure a better working environment and more effective workspace. A requirement is made later regarding cross infection. Recruitment records were examined and references and Criminal Record Bureau Checks did not satisfy regulations. This does not ensure that the safety of service users is safeguarded by a robust recruitment procedure. Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 14 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): 33 & 38 The safety of service users is not assured through health and safety protocol in the home. EVIDENCE: Cleaning products and a sharps bin were not safely stored on the day of inspection. Soiled linen in the laundry is not appropriately stored. Bags are kept near to clean linen. The pressure placed upon staff in the laundry has resulted in safe practice being compromised. Space is inadequate for clean clothes to be stored appropriately. This provision must be reviewed. The Inspectors are aware that provision will be moving next year but measures must be taken to ensure good health and safety and that infection control is observed. A requirement has been made to provide the Commission with results of a quality assurance audit. Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 15 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 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X 2 X X STAFFING Standard No Score 27 1 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X 2 Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 16 Are there any outstanding requirements from the last inspection? Yes 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 2 Standard OP3 OP7 Regulation 12(1) 12(1)(a) Requirement The home must only admit service users for which it is registered. Risk assessments must be reviewed to ensure appropriateness and accuracy. Care plans must adequately inform staff how an identified need is managed e.g. sensory impairment, epilepsy. THIS REQUIREMENT REMAINS UNMET FROM THE PREVIOUS INSPECTION. A safe system of medication recording and monitoring must be in place. THIS REQUIREMENT REMAINS UNMET FROM THE TWO PREVIOUS INSPECTIONS. Staffing levels must be adequate to meet the needs of the service users. Staff must be afforded adequate time off and work hours that ensure service users are properly cared for. The home manager must evidence that all staff have an appropriate Criminal Record Bureau check and two references DS0000038639.V264976.R01.S.doc Timescale for action 15/12/05 31/12/05 3 OP9 13(2) 15/12/05 4 OP27 18(1)(a) (1)(b) 15/12/05 5 OP29 19 17(2) 18/11/05 Borehamwood Care Village Version 5.0 Page 17 6 OP33 24 kept on the premises. THIS REQUIREMENT REMAINS UNMET FROM THE PREVIOUS INSPECTION. An action plan must evidence how staff who have been employed without these checks are managed appropriately and service users are not exposed to risk. An immediate requirement was made. The Commission must be provided with results of a quality assurance audit. The health and safety of service users must not be compromised. Infection control must be observed. 31/12/06 7 OP38 13(4)(c) 10/12/05 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. hoisted from a wheelchair, assisted with a meal etc. Activities should be provided daily. The dining rooms (Regency) should better facilitate a positive dining experience. Bedrooms should reflect the personality of the occupant and some are impersonal. 2 3 4 OP12 OP15 OP24 Borehamwood Care Village DS0000038639.V264976.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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. 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