Inspection on 23/10/08 for The Borrins

This inspection was carried out on 23rd October 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Borrins 26/10/07

The Borrins 07/11/06

The Borrins 08/12/05

The Borrins 30/05/05

The Borrins 02/12/04

The Borrins 01/06/04

The Borrins 16/03/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE The Borrins Station Road Baildon Shipley West Yorkshire BD17 6NW Lead Inspector Catherine Paling Key Unannounced Inspection 23rd October 2008 10:40 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 The Borrins DS0000001239.V372884.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. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Borrins Address Station Road Baildon Shipley West Yorkshire BD17 6NW 01274 582604 01274 598066 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) www.bupa.co.uk BUPA Care Homes (GL) Ltd Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (28), Physical disability over 65 years of age (4) of places The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2007 Brief Description of the Service: The Borrins provides personal care without nursing for up to 32 people over the age of 65. The home is located near the centre of Baildon, a quiet suburb on the outskirts of Bradford. It is not far from the village centre and shops. The building is a period property, which has been adapted while keeping many of its characteristics. It stands in attractive grounds and car parking is available. The gardens are well maintained and easily accessible with walkways and plenty of seating. Accommodation is in mainly single bedrooms. Some of the double rooms are currently being used as singles, which means that the homes maximum occupancy level is 28. There are two comfortable lounge areas with views of the gardens and a dining room. Information about the home is kept in a file in the reception area as well as in people’s rooms. Information packs are posted to people on request. The current charges range from £377.79 to £696.00 per week. Items not covered by the fee include newspapers, hairdressing and chiropody. This information was provided at the inspection of October 2008. The home should be contacted directly for up to date information about charges. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1star. This means the people who use this service experience adequate quality outcomes. This was an unannounced visit by one inspector who was at the home from 10:40 until 17:00 on 23rd October 2008. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and the staff. An Annual Quality Assurance Assessment (AQAA) had been requested by before the visit to provide additional information. This is a self-assessment of the service provided. This was not returned to us in time for this visit. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home, visitors and healthcare professionals who visit to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned and comments are included in the body of the report. What the service does well: The home has information available to people about the service to help them make up their mind about moving in. The home is clean, tidy and well maintained. It is welcoming and homely people can bring in their own belongings to personalise their rooms. The atmosphere in the home is warm and friendly. Visitors said that they could visit the home at any time and that they were made welcome. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 6 People said: “The Borrins is friendly and homely. My mother is happy” “Personal care good. Respect for individuals” “Overall, I think the care my mother receives is the best available” “Good food” “Plenty of care and good humour” 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. The Borrins DS0000001239.V372884.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 The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 (Standard 6 does not apply to this service) People who use the service experience good quality outcomes in this area. People are provided with enough information to help them to make an informed choice about the home. Pre-admission assessments are carried out to make sure that people’s care needs can be met. We have made this judgement using available evidence including a visit to this service. EVIDENCE: There is information about the services provided at the home available in the reception area. There is also a file in every bedroom containing useful information about the services and facilities at the home. The new manager is aware that some of the information needs updating. She also wants to personalise the information by including detail of someone’s key worker. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 9 Everyone has their care needs assessed before admission to the home using the detailed assessment documentation. People’s care needs are re-assessed on admission and this provides a trigger for staff of the support people need and therefore what needs to be included in care plans. People said: They had been given all the information they needed about the home and the services it provided. “The Borrins is friendly and homely. My mother is happy” When their relative had moved in their room had not been ready causing some distress. The Borrins DS0000001239.V372884.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 and 10 People who use the service experience adequate quality outcomes in this area. Overall, care plans contain enough detailed information about individual needs so that staff know how to look after people properly. Staff respect the privacy and dignity of the people living at the home. People at the home are protected by safe medication practices. We have made this judgement using available evidence including a visit to this service. EVIDENCE: We looked at a small sample of care records in detail. The information and levels of detail varied from being detailed and person centred to quite basic and not fully up to date. The manager is starting to get to know people and has begun looking at records and is already aware of the shortfalls, which have been identified previously. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 11 One person had been admitted to the home in June and there was no information on the Lifestyle profile. We saw some other records with good and detailed Lifestyle profile. Some of the care plans written in June immediately following admission had not been updated. For example, a communication plan noted that an optician’s appointment was needed but had not been updated following the opticians visit and did not note the outcome. A plan concerned with mobilising noted that this person needed two people to help at first but now she only needs one. Care must be taken to make sure that the most up to date information is easily accessible to staff so that they know how to look after someone properly. Other documents in these records were not fully completed, such as some of the risk assessment documentation. Evaluation and review of care plans was variable and some was overdue. Overall, the monthly reviews did not provide detailed comment on the effectiveness or success of care plans for the previous month. Daily records were kept but we saw that gaps were often left between entries and this should stop. Staff also should avoid subjective statements such as ‘very demanding’ or ‘in a good mood’. Daily records should give information about the health and well being of a person. We saw records of the input of other healthcare professional. These records seemed to be rather muddled in some cases making it hard to get to the most up to date information about any healthcare needs or changes. The staff do know the people they look after very well and we saw them approach people with kindness and patience. People said: “I am quite immobile and need help to stand and walk….should be doing regular exercise…no-one comes to help me to do this”. “I am happy with the level of care and attention my father receives. He has been very happy at the Borrins for almost two years”. “Well meaning and generally good basic care lacks specialist care for her condition – more and more isolated due to dementia” “Personal care good. Respect for individuals” “Overall, I think the care my mother receives is the best available” Senior care staff look after people’s medications. All successfully complete training via BUPA before they get involved in medications. The new manager intends to assess the administration of medication so that she can be satisfied that practices are safe. The deputy manager said that the home get very good support from their supplying pharmacy. The Borrins DS0000001239.V372884.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 and 15 People who use the service experience good quality outcomes in this area. People are supported in maintaining contact with their family and friends and visitors are welcomed at the home. Overall, people said that have enough to occupy them through the day so that they were not bored. We have made this judgement using available evidence including a visit to this service. EVIDENCE: People told us that they were able choose and had control over how and where they spent their time. They said they could get up and go to bed when they wanted to, they could stay in their rooms or come into the lounges, choose where to eat their meals and whether or not they wanted to join in with activities. Those who were able went out with family or friends. Visitors are made welcome at the home. There is a part time activities coordinator and there is a regular programme of The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 13 events in the home. This is an area that the manager is aware needs to be developed and she is looking to do so. On the day of the visit some people were taking part in a quiz, with lots of laughter and obvious enjoyment. Others were watching television and one person was looking forward to watching a football match that evening. Another person had already been talking to the manager about having a greeenhouse. The kitchen is well staffed by experienced people who know the likes and dislikes of the people they cater for. There is home baking, including bread, and people enjoy the food. The manager is keen to work with the catering staff to make some minor changes to make sure that drinks and snacks are more freely available throughout the day in the lounges to people and their relatives. People said: Meals – “plenty of choice” “Good food” “Plenty of care and good humour” Do well? – “Outings and activities” “Food is excellent and varied with choices” “My Mother is always inside even on hot sunny days. When I take her outside she loves it”. “Entertainment, games and outings are provided on a regular basis”. “I am usually made welcome but I have to ask for a coffee normally”. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience good quality outcomes in this area. There is a complaints procedure and people feel that any concerns will be taken seriously. People feel safe at the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: There is a clear complaints procedure in place at the home. It is displayed in the entrance area and is made available to everyone in the information files found in bedrooms. Records are kept of complaints received and monthly returns are made to head office about any complaints received. The new manager is to attend safeguarding training in January 2009 to enable her to provide safeguarding training to staff on an ongoing basis. People we spoke with told us that they are confident that they can speak up and will be listened to about any concerns. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. People live in a safe, comfortable and well-maintained environment. We have made this judgement using available evidence including a visit to this service. EVIDENCE: We visited parts of the home used by the people living there and all areas were clean and fresh smelling. Overall, the home is in need of further refurbishment and redecoration and some areas were looking rather ‘tired’. The manager told us that there are plans in place for the refurbishment of the home but she was unsure of the detail as yet. She had a meeting planned with her manager to look at ways of improving the facilities as part of the refurbishment plans. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 16 A new fully assisted communal shower room had just been completed and was ready for use once a shower chair had been purchased. This work has been done to a high standard and this will enhance the existing communal bathing facilities. The laundry is situated in a separate annex. It is spacious and was clean and looked very well organised. There were hand washing facilities but no soap dispenser or paper towels. Although there seemed to be good practices in place regarding the control of infection proper hand washing arrangements should be made in the laundry. People said: “Door from my room to the garden- difficult to open and it is draughty. The room is very nice”. “Skip of rubbish since I came” “Front door and porch need a good clean” “Home clean and fresh smelling at all times” “Recent repairs and improvements have been noticed – simple maintenance has not been followed up” “Clothes are laundered and pressed beautifully” The gardens are attractive and there is a sensory garden for people to enjoy when weather permits. There are walkways and plenty of seats for people to use. Most of the rooms enjoy a pleasant outlook however there was a skip at one side of the building, which looks as though it had been there for sometime. The manager said she would make arrangements for it to be removed. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. A trained and competent staff team cares for people although sometimes people feel that there are not enough staff. People are protected by robust recruitment procedures. We have made this judgement using available evidence including a visit to this service. EVIDENCE: There have not been any changes to staff numbers since the last inspection and views from people expressed concerns about staffing numbers. People said: “Could improve staffing levels”. “Sometimes there are too few”. “Those here work very hard”. “Most of the staff are very caring”. “Appears to be short staffed”. “Staffing levels are adequate but not strong”. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 18 “Occasionally it appears that home routines are for the benefit of (low) staffing levels rather than for the benefit of individuals”. There were twenty-three people living in the home. Four staff give care and support to people in the morning; three in the afternoon and usually two overnight. The night staffing levels are currently three following the most recent fire safety report. The manager said that she felt there were enough care staff and the organisations view is that these numbers are adequate for the needs and numbers of people living in the home. There have been issues with staff changes and possibly deployment of staff and the manager is looking at the way staff work to make sure that they are working effectively to meet people’s needs and look after them properly. Care staff have the support of an ancillary staff team that includes domestic, laundry and kitchen staff. There is administrative support and this person currently gives some hours to activity organisation, although this will stop at Christmas. The manager is looking to appoint a new activities person for 20hours a week. Staff are provided with plenty of training opportunities to help them understand what they do and look after people properly. The majority of staff have achieved a National Vocational Qualification (NVQ) in care at level 2 and some have moved on to and achieved NVQ level 3. A further 6 staff are working towards NVQ level 3. The recruitment processes and procedures make sure that everyone has the required checks carried out before they start work at the home. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. The management of the home is committed to making sure that practices promote and safeguard the health, safety and well being of people living at the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The new manager had been in post for only five days at the time of this visit. She told us that the previous manager had given her a handover the week before and now she was learning about the people living at the home and the staff. There have been a number of changes in management over recent The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 20 years and this means that there has been a lack of continuity in the way the home has operated. The new manager is a qualified nurse and maintains her registration with the Nursing and Midwifery Council (NMC) through regular update. However, regulation requires her to consult with the community nursing service where people at the home have nursing needs. She has worked with BUPA for some years and is experienced in care. She has started working towards the Registered Managers’ Award (RMA) in June 2008 and will make application to be registered as soon as possible. In the very short time she has been at the home she has already started to work out what her priorities are in order to develop and improve the service provided to the people who live at the home. People told us at the last inspection that they thought that the manager was ‘hidden away’ at the top of building and isolated from what was happening in the home. The manager’s office is on the top floor but there are no other areas in the building that would be suitable to use. The new manager is very conscious of this and makes a point of walking round the building to see everyone when she comes on shift and before she goes home. She is determined to be an obvious presence in the home and accessible. Comments received before our visit in surveys indicate that people do want better communication. Some are satisfied but others want further improvement in communication to include formal care reviews. People said: “Good communication with my father and myself” “Communication has improved. Regular reviews of care plans would provide formal means of discussion rather than ad hoc”. The manager intends to arrange more formal contact with people living at the home and their relatives when she has been in post a little longer. This could take the form of a social evening nearer Christmas. She has already organised meetings with all designations of staff and was getting to know staff and their skills. The experienced deputy manager who has been at the home for a number of years provides support for the manager. The manager also has the support of the responsible individual for the company. This person is required to visit the home at least once a month and has been providing support with frequent contact. She was due at the home the day after our visit. The home does not look after people’s finances. The administrator will look after small amounts of personal allowances brought in so that people can have access to money at any time. This money is banked in interest bearing The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 21 accounts and appropriate records are kept of all monies received and returned to people. West Yorkshire Fire Service identified significant fire safety issues in a fire safety inspection in 2007. The manager said that the remedial work was planned before the end of the year. In the meantime an additional member of staff is on the night shift, on fire watch. The AQAA had not been returned before this visit and it seems that it has been overlooked during the changes in management. The Borrins DS0000001239.V372884.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 2 9 3 10 3 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 4 Refer to Standard OP7 OP8 OP27 OP33 Good Practice Recommendations Care records should be detailed and person centred so that staff have the information to look after people in the way they want. Care should be taken to make sure that the information in care records is complete and up to date so that staff are working with current information. The number of care staff and the methods of deployment should be kept under review to make sure that there are enough staff to look after people properly. The manager needs to make sure that she effectively monitors the service provided. Opportunities should be given for people contribute to the running of the home, through effective communication systems. The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Borrins DS0000001239.V372884.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!