Inspection on 23/05/06 for Forest Care Village Elstree & Borehamwood

This inspection was carried out on 23rd May 2006.

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

Other inspections for this house

Forest Care Village Elstree &... 12/05/08

Forest Care Village Elstree &... 15/05/07

Forest Care Village Elstree &... 13/03/07

Forest Care Village Elstree &... 17/11/05

Forest Care Village Elstree &... 16/06/05

Forest Care Village Elstree &... 15/09/04

Forest Care Village Elstree &... 15/06/04

Forest Care Village Elstree &... 28/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Borehamwood Care Village 10-20 Cardinal Avenue Borehamwood Hertfordshire WD6 1EP Lead Inspector Mrs Judith Kent Key Unannounced Inspection 23rd May 2006 09:50 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.V295541.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.V295541.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 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.V295541.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). 17th November 2005 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. Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over almost ten hours and was carried out by four inspectors. Service users and staff in each of the three units were spoken with and discussions with the acting manager, Mr Mike Horne, and the company’s recently appointed Director of Operations, Ms Caroline Stoner, took place during and at the end of the inspection. Much of the inspection concentrated on the newly opened dementia care unit. Although the home has doubled it’s number of beds to 179 recently, only 106 were occupied at the time of the inspection. The refurbishment of the home has not yet been completed – both the laundry and kitchen on the top floor are due to be resited and enlarged to meet the increased needs of the home. The home is mainly staffed by overseas trained nurses who are going through ‘adaptation’ to gain recognition as nurses with the Nursing and Midwifery Council (NMC)in the UK. There are also a number of fully qualified nurses on site and a small number of care assistants as well as catering and housekeeping staff, an administration team and a senior management team. CSCI questionnaires about the quality of the service were left at the home eight service users, one relative and one visiting GP completed and returned them. Service users were generally satisfied with the care given in the home and by the approach and attitude of staff members, although there were comments that response time to the call bells is sometimes lengthy and that service users have difficulty communicating with some of the overseas staff members; the catering in the home was mostly appreciated by service users; inspectors found the environment to be clean and well-maintained in most areas, although there were some health and safety issues raised. What the service does well: Inspectors saw some good care taking place – care staff showed a calm and patient approach to service users and feedback from service users themselves confirmed that staff are mostly caring and responsive. Comments from service users about the catering in the home were mostly positive. The home is kept clean and odour-free by the housekeeping staff. Borehamwood Care Village DS0000038639.V295541.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. Borehamwood Care Village DS0000038639.V295541.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.V295541.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 (Standard 6 is not applicable.) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users’ needs are assessed before they move into the home. However, the new dementia care unit is not yet able to provide a service which will meet the needs of the people who live there. Service users are experiencing problems communicating with some staff members. The information given to service users is out of date and could mislead. EVIDENCE: The Statement of Purpose and Service Users’ Guide are comprehensive and hold good information for service users, but they have not yet been revised and updated to include the provision of dementia care and changes in the staffing arrangements in the home. Service users pre-admission assessments were looked at and were found to have been completed with the necessary information to enable the home to be sure that their needs can be met by the service. There were concerns about the recently opened unit for people with dementia which have been set out in several sections of this report – at the time of the Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 9 inspection the home was not able to fully meet the very specialist needs of people living on the dementia care unit as required by the National Minimum Standards and the Care Homes Regulations. Many service users who spoke to inspectors or returned questionnaires said that there were language difficulties with some of the care and nursing staff who do not have a good command of English. This can lead to misunderstandings, a breakdown in communication and the possibility that individual needs are not met. Borehamwood Care Village DS0000038639.V295541.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are not reviewed with service users so may not reflect current needs. Medication administration, recording and storage is not always compliant with good practice guidelines. Service users health could be at risk if staff are not able to follow instructions and procedures. EVIDENCE: Inspectors noted good interaction between staff members and service users, particularly on the dementia care unit where staff showed a caring approach and spoke calmly and reassuringly to service users. Elsewhere in the home staff were seen to approach people quietly and offer appropriate support. Care plans and risk assessments were looked at on each of the units within the home and while they were well set out and recorded clear care objectives, several did not reflect what was happening in practice, nor was there any indication of service users’ involvement in developing them or of reviews taking place. In particular, concerns were raised and discussed about the recording of pressure ulcer care and continence management. There were no Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 11 risk assessments recorded for at least two people who look after their own medication The use of restraint for one service user who was strapped into a wheelchair was raised with the management team as there was no risk assessment for either the use of the wheelchair or the method of restraint. Rigorous risk assessments must be completed to make sure that service users are protected from harm in an acceptable and appropriate way which should not include restraining people by means of straps. A GP who has patients in the home completed a CSCI questionnaire and expressed concern about the ability of some of the nursing staff to understand instructions and procedures. There were concerns about how medication is stored, administered, recorded and monitored in the home. There were some discrepancies between the amounts of medication held and the records on the Medicines Administration Record (MAR) sheets; the temperature of at least one of the rooms where medication is stored was not monitored; records were not always accurately kept; the system for auditing is not effective. Several service users commented on the delay in returning clean clothes from the laundry due to one washing machine being out of action; one relative spoke of her father not having a clean vest and being dressed in pyjama trousers and dirty shirt as there were no clean clothes for him. It was agreed at the inspection that the home would take immediate steps to deal with the backlog of laundry so that service users clothes are returned to them without delay. Inspectors noted some use of inappropriate language and terminology among staff members – this was discussed with the management team at the end of the inspection. Some service users in the dementia care unit looked unkempt, with missing socks and stockings and in one case no trousers – his legs were covered by a blanket. Several service users spoke to inspectors about the sometimes long delay in responding to call bells and the poor and uncaring response of some staff members. Borehamwood Care Village DS0000038639.V295541.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 at least once during a 12 month period. 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. Service users are able to take part in activities, although there is a need for additional staff resources to provide a full range across all the units in the home. Catering in the home is of a good standard but the use of more fresh and home-cooked food would add to the quality of the menus offered. Service users do not always get the help they need to eat their meals. EVIDENCE: One full-time activities organiser is employed in the home. She has developed a programme of activities and also spends time with service users on a one-toone basis. However, it is clear that in a home of this size, additional input is needed to make sure that service users are able to reach their full potential and maintain a good quality of life, especially on the dementia care unit. No records of activities or those taking part are kept. There is transport available and service users can take trips out to enjoy shopping or visits to places of interest. The menus seen were balanced and there is always a vegetarian option available for those who may not like the main course offered. Service users are asked to choose their menu on the previous day and two people reported that their choice was sometimes not available. Some poor practice was seen during Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 13 the lunch service – people who needed help to eat were left to fend for themselves and their food was left to get cold; people were not encouraged to eat by staff; drinks, though available, were not offered. Discussion with the catering staff revealed that while the kitchen tries to offer at least one fresh vegetable each day, there is a good deal of reliance on frozen vegetables and prepared meals, as with the increase in the number of service users with no additional chef time and the lack of maintenance on kitchen equipment, the chefs are unable to prepare and cook everything on the premises. While service users were generally pleased with the catering in the home, there were a few negative comments and it is important that the catering staff talk to service users to find out their likes and dislikes, how they feel about the catering and to listen to any suggestions they might make. Borehamwood Care Village DS0000038639.V295541.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 inspected at least once during a 12 month period. 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. Complaints are not dealt with within the required timescale. Staff members are not all aware of adult protection procedures, as a result of which service users could be placed at risk of abuse or neglect. EVIDENCE: The complaints procedure in the current Statement of Purpose does not set out timescales in which any complaints made about the service will be dealt with. The acting manager said that there had been three written complaints received in the home; however, the CSCI had been copied in to a further two. The information at the inspection was that all had been dealt with or were ongoing, although one complainant had reported to the CSCI that she had not heard from the home for several weeks. The Care Homes Regulations set out a timescale of 28 days for response to complaints, but this is clearly not held to by the home. There is a whistle-blowing procedure for staff, some of whom were aware of their responsibility to report any suspicion or allegations of abuse of service users to the manager. However, there is an urgent need for staff to have training in adult protection and to be fully aware of the Hertfordshire County Council Adult Protection procedure. Borehamwood Care Village DS0000038639.V295541.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Many areas of the home are maintained to a good standard, but the dementia care unit is in poor shape – service users safety is at risk. The service areas in the home (main kitchen and laundry) have broken equipment; as a result the quality of the service provided is not of a standard that service users should expect. EVIDENCE: While inspectors found that all areas of the home used by service users were clean and odour-free, there were some issues about the readiness of the dementia care unit to admit service users. There were several safety concerns about the unit including that there were no handles or locks on bathroom and toilet doors, on the room where medication is stored, and on the room where cleaning materials are kept, which was also missing a pane of glass in the window onto the corridor; sliding doors on the small kitchen and toilet were Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 16 unsecured at the bottom; the electric kettle in the small kitchen (accessible to service users too) was on a low table as there was no space on the worktop. In addition it seems that not enough thought had gone into preparing the unit for people with dementia, for whom orientation aids are essential. One of the two washing machines in the laundry on the second floor had been out of commission since the beginning of April, causing a vast backlog of laundry to build up. Since the laundry bags also contained soiled linen, albeit sealed into degradable bags, there is a high risk of cross-infection. It was proposed that the backlog be sent to a commercial laundry to be dealt with. The long turn round time for service users’ clothes as a result of the broken machine was commented on by both service users and one relative. The acting manager said that a new washing machine was on order, but had not yet been delivered. The main kitchen in the home is due to be moved and refurbished. Discussion with the catering staff revealed that several of the main pieces of equipment – ovens, gas rings, electric fly killers – were out of order and had been for some time. Although the kitchen was generally clean and the Environmental Health Officer who visited in December 2005 had made no requirements, the storage bins for dry goods (flour, sugar, cereal etc) were dirty and need to be cleaned. The chefs said that they had recently devised a cleaning schedule for the kitchen assistants which was awaiting management approval. There were not sufficient tables in the dining room for all service users to be able to sit at meals together. As a result some people remained in their chairs to take their lunch and indeed hardly moved from them throughout the day. Borehamwood Care Village DS0000038639.V295541.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The failure to follow safe recruitment practice could place service users at risk of harm. Service users do not benefit from a stable and settled staff group. Little training beyond the mandatory requirements takes place and there are no records to show training that staff members have attended. EVIDENCE: In addition to the senior nursing staff the care staff group is made up mainly of overseas ‘adaptation’ nurses who are seeking recognition by the Nursing and Midwifery Council (NMC) or who have done their adaptation and who have stayed on at the home as health care assistants. The result of having such a high volume of adaptation nurses is that they often move on from the home after completing their training, with the result that service users are having to adapt to a constantly changing staff group. However, the plan for the future is to recruit the majority of staff, who will be designated as care workers rather than nurses or health care assistants, from the local community. This will provide more continuity for service users, especially important for the people on the newly opened dementia care unit. Examination of the files of the most recently recruited staff members showed that again there was no evidence that Criminal Records Bureau (CRB) or Protection of Vulnerable Adults (POVA) checks had been completed. The Human Resources manager on site said that these were kept at the company’s head office, but it is a requirement of the Care Homes Regulations that these Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 18 are available for examination on site. Three of the four files seen were also missing one or both of the required references. The increase in numbers in the home indicates that both the catering and laundry facilities and staffing levels need urgent review, and there is a need for additional staff to organise and run activities for service users. There were no training records available at the inspection and the acting manager was unable to give any information about mandatory or other training which had taken place since the last inspection. It was confirmed after the inspection that of the six careworkers in the staff group, one already holds the National Vocational Qualification (NVQ) Level 2 in Care and the remaining five have started working towards the qualification. Although a short 1½hour session had been arranged for the day after the inspection, there is an urgent need for in-depth training in dementia for those people who work in the dementia care unit, so that they can develop an understanding of the special needs that service users may have. Borehamwood Care Village DS0000038639.V295541.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There has been poor management of the recent opening of the dementia care unit, which was not ready to admit service users and where staff members have not had adequate training in caring for people with dementia. Both quality and health and safety audits are carried out, but there has as yet been no consultation with service users to seek their views. There is some unacceptable care practice which could result in the safety of both service users and care staff being put at risk EVIDENCE: There has been an acting manager in charge of the home since the registered manager moved to another home at the end of March this year. However, after this inspection a decision was made that the Director of Operations for the company, Ms Caroline Stoner, would take over the running of the home on a Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 20 full-time basis until a manager who the company will put forward for registration with the CSCI has been recruited. The recently opened dementia care unit is in particular need of strong management input – it had been open for five weeks at the time of the inspection and inspectors were not satisfied that admissions had been managed well or that it was functioning effectively. Staff on the unit have little experience or training in looking after people with dementia and little thought appears to have been put into preparation of the unit to receive service users. A strong recommendation from this inspection, raised during the feedback, is that the company recruits a suitably qualified and experienced manager specifically for the dementia care unit. A quality audit in relation to housekeeping and care plans was being carried out by the Director of Operations on the day of the inspection, and health and safety audits are completed by the General Services Manager. However, there has been no survey of service users, relatives or other stakeholders to find out their views on the quality of the service provided, and the requirement that a full quality monitoring exercise is carried out is repeated in this report. Inspectors noticed the use of unacceptable moving and handling techniques and wheelchair brakes and footplates not being used - all mandatory health and safety training must be updated and care practice must be monitored to ensure the welfare of service users. Inspection of the accident records showed that the CSCI has not been informed of many of the accidents and incidents or that had occurred in the home. In addition, incidence of pressure ulcers of Grade 2 and above must be notified to the CSCI. Examination of one person’s care plan showed that he had sustained a fracture to his arm, but no record could be found of this in the accident record book; another care plan recorded that a service user had left the dementia care unit and had made his way home, but had not been missed until his wife rang the home and told the staff where he was. The chefs reported that they were unable to clean the meat slicer thoroughly due to the absence of a guard for the blade. The safety and security of service users was discussed with the management team at the end of the inspection as one inspector had noted that a service user had left the home unnoticed and had not been missed for some hours. Borehamwood Care Village DS0000038639.V295541.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 2 x 3 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 1 2 x x x x x 1 STAFFING Standard No Score 27 2 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 1 Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 22 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 Standard OP1 Regulation 4&5 Requirement The Statement of Purpose and Service Users’ Guide must be revised and amended to reflect current circumstances. The registered person must ensure that the home is staffed by suitably qualified and experienced people, especially in the dementia care unit, and staff must be able to communicate effectively with service users Risk assessments must be reviewed to ensure appropriateness and accuracy. Care plans must adequately inform staff how an identified need is managed. (This requirement remains unmet from the previous inspection) Pressure ulcer care and progress and continence management must be recorded on service users’ care plans. A safe system of medication storage, administration, recording and monitoring must be in place. (This requirement remains unmet from the two DS0000038639.V295541.R01.S.doc Timescale for action 31/08/06 2 OP4 18(1)(a) 23/05/06 3 OP7 12(1)(a) 31/07/06 4 OP8 17(1)(a) & Sch 3 13(2) 23/05/06 5 OP9 23/05/06 Borehamwood Care Village Version 5.2 Page 23 previous inspections) 6 7 8 9 10 OP10 OP10 OP16 OP18 OP19 16(2)(e) 12(4)(a) 22(4) 13(6) 23(2)(c) Proper arrangements for the laundering of service users clothes must be in place. Service users dignity must be respected and promoted Complaints about the service must be dealt with within twenty-eight days of receipt All staff must have training in adult protection and procedures for reporting suspicions of abuse All catering and laundry equipment must be repaired or replaced to enable staff to do their work safely and to protect service users’ health and welfare There must be provision for each service user to be able to sit at a table in a dining room to take their meals The manager must ensure that there is sufficient, working laundry equipment to deal with the volume of laundry generated in the home; and that the backlog is dealt with immediately. The home manager must evidence that all staff have an appropriate Criminal Record Bureau check and two references kept on the premises. (This requirement remains unmet from the previous two inspections) The home must maintain a record of all training, including induction, undertaken by each member of staff. The Commission must be provided with results of a quality assurance audit. (This requirement remains unmet from the previous inspection) DS0000038639.V295541.R01.S.doc 23/05/06 23/05/06 23/05/06 31/08/06 31/07/06 11 OP20 23(2)(g) 31/07/06 12 OP26 13(3) 23/05/06 13 OP29 19, 17(2) 23/05/06 14 OP30 17(2) & Sch 4 24 23/05/06 15 OP33 31/08/06 Borehamwood Care Village Version 5.2 Page 24 16 17 16 OP38 OP38 OP38 13(4)(c) 37 23(2)(c) The health and safety of service users must not be compromised. Accidents and incidents must be fully recorded and reported to the CSCI. Equipment in the home must be maintained in good working order to protect both staff and service users Monthly proprietor’s visits reports must be regularly received by the CSCI. 23/05/06 23/05/06 23/05/06 17 *RQN 26(3) & (5) 23/05/06 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 3 Refer to Standard OP12 OP12 OP27 Good Practice Recommendations The dementia care unit should have a dedicated full-time activities organiser Records of activities taking place and service users’ participation in them should be kept. It is strongly recommended that a suitably experienced and qualified person be appointed to manage the dementia care unit. Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Borehamwood Care Village DS0000038639.V295541.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!