Inspection on 26/10/07 for The Borrins

This inspection was carried out on 26th October 2007.

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.

Other inspections for this house

The Borrins 23/10/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Borrins Station Road Baildon Shipley West Yorkshire BD17 6NW Lead Inspector Nadia Jejna Unannounced Inspection 10:30 26 October 2007 th 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.V345263.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.V345263.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 jaggert@bupa.com www.bupa.co.uk BUPA Care Homes (GL) Ltd 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) vacant post 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.V345263.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th November 2006 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 its own grounds and car parking is available. The gardens are pleasant and well maintained providing pleasant sitting areas that are easily accessible to residents. Accommodation is provided in mainly single bedrooms. Some of the double rooms are 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 services provided by the home is kept in a file in the reception area as well as in residents’ rooms. Information packs will be posted to people on request. At the time of writing this report the homes charges for residential care range from £352 per week to £650. Items not covered by the fee include newspapers, hairdressing and chiropody. This information was provided in November 2007. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started on 26 October and was completed 9 November 2007. The home did not know that this was going to happen. Feedback was given to the manager during and at the end of the visits. The purpose of this visit was to make sure that the home was being managed for the benefit and well being of the people using the service. During the visit residents, their visitors and staff were spoken to. Records such as staff files, complaints and accidents records were looked at. Before the visit was planned the provider was asked to carry out a quality assessment of the service stating what they did well, what was in place to prove this, what improvements had been made over the last twelve months and what was planned for the year ahead. This document is called the Annual Quality Assurance Assessment and will be referred to in the report as the AQAA. Other information asked for included what policies and procedures are in place, when they were last reviewed and when maintenance and safety checks were carried out. Questionnaires were sent to people living in the home, their relatives and healthcare professionals before the visit took place. These people were selected using information provided in the AQAA. When the visit took place no surveys had been returned from people living in the home but there were five from relatives, three from healthcare professionals and three from staff. The information from these was used to inform the visit and is referred to throughout the report. What the service does well: Information about services provided by the home is available and lets residents and their relatives decide if the home will be suitable for them. The home is clean, tidy and well maintained and is decorated and furnished to a good standard. 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; they were made welcome and were offered refreshments by staff. This makes it a pleasant, comfortable and homely place to live. Information from people living in the home, their relatives and from surveys returned said: The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 6 • • • • • • They were kept up to date about changes in people’s condition, for example if they became ill or had an accident. The food was good, they had choices at mealtimes and they got plenty to eat. The care and support provided was as expected and they were happy the services provided by the home. Staff help people to maintain their well being in a calm and supportive environment. One person said that ‘The staff’s commitment to the dignity and individuality of residents is admirable.’ More activities are being provided and they can choose whether or not they want to join in. What has improved since the last inspection? What they could do better: The organisation could look at making sure that there is some continuity in the way the home is organised and managed. This will benefit people living in the home, as well as staff and help to continue improving the quality of services provided. Other areas where changes would make outcomes for people better include: • Making sure all staff have received training that helps them to understand and meet peoples needs. Particularly around maintaining the health, safety and well-being of people and specialist healthcare needs such as dementia. • Making sure that there are always enough staff on duty to meet peoples needs. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 7 • Making sure that the manager is registered with the Commission as soon as possible. This will mean that people who live at the home can be reassured that their home is being managed by someone who is qualified and trained to do so. 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.V345263.R01.S.doc Version 5.2 Page 8 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.V345263.R01.S.doc Version 5.2 Page 9 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, 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have enough information about the service to be able to decide if it will be suitable for them and their needs are assessed so that the home can be sure it can meet them. EVIDENCE: Information about the services provided by the home is available in the reception area. Files of useful information are placed in every bedroom. In the AQAA the manager said that there were plans to improve and update the homes brochure and that the information packs now contained a list of questions for people to ask to help them make an informed decision about the home they are looking at. The relative of somebody who had moved into the home a few months ago said that they had been to look round and been given information packs and brochures. They had also brought their relative to visit the home before agreements were made about moving in. This had let their relative look round, meet other people living in the home and some of the staff. Before their The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 10 relative moved in the manager visited them at home to assess their care needs. This assessment was seen in the care plan and it provided enough information for the manager to be sure the home could meet their needs. The manager said that all people who want to move into the home have a pre admission assessment carried out before any agreements are made. If they do come to live at the home their needs are assessed again on admission to see if there have been any changes. Care plans looked at confirmed that this happened. Some people living in the home have some form of dementia and the manager said that training about this has been given to some of the staff. The manager was reminded that the home was not registered to provide care to people whose main reason for needing residential care is because they have dementia. Information from people living at the home and their relatives said that: • They had been given all the information they needed about the home and the services it provided. • One person was very happy with the way their relative had settled into living at the home and that they were mixing well with other people and staff. • Most people had received copies of the contracts for care and services provided. Some said it could take a while for the three way contracts between them, the home and the local authority to be supplied. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples personal and social care needs are set out in care plans that provide staff with guidance about how to meet them. This would be better if the links between healthcare assessments and the care plans were maintained making sure that specialist health care and support would be asked for in a timely manner. EVIDENCE: Since the last inspection in November 2006 the organisation has introduced a new system of care planning to all of its care homes. Training and guidance about how to use it has been given to staff. The aim is to make sure that all people living in their care homes have detailed, individual, person centred care plans that provide staff with all the information needed to meet their needs. After the training sessions had taken place all the care plans had to be switched over to the new format within a set timescale. Staff have worked very hard to meet the deadlines set by the organisation and are still getting used to the new systems. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 12 Four care plans were looked at during the visit. The information and levels of detail varied from being very good and person centred to basic and not individual to the person it was about. The manager is aware of this and said that they were auditing the care plans to identify where staff need more help, support and training. A senior carer had come into the home on the day of the visit to review some of the plans they had written and make changes to them. From talking to staff it was clear that they had a good understanding of people’s needs. Example of areas where more information was needed are: • The eating and drinking care plan for somebody who had lost weight did not follow the organisation’s guidelines on nutritional assessments. It did not say if the GP or dietician had been contacted for advice. There was no information about the person’s dietary likes/dislikes or what steps should be taken to enrich their diet. The kitchen staff did not know that this person needed an enriched diet. Staff were not monitoring their diet and fluid intake other than occasional references to either ‘not eating because they were asleep’ or that they had ‘eaten well’ in the daily records. • Falls risk assessments are being carried out. But the care plan looked at repeated the information from the assessment and did not say what was being done to reduce the risk. It was not clear if the falls prevention team had been contacted for specialist advice and support. • One person had left the home on two occasions and staff said they needed to be aware of their whereabouts. But there was no risk assessment or care plan to say how this would be done. Information from healthcare professionals who visit the home said that staff sought advice about people’s healthcare needs. But there was one comment that sometimes communication between staff and at shift changeovers was not as it should be. An example was given of a person who needed to return to see the GP in a set time period and this was not done. Senior care staff look after peoples medications. They have received certificated training to help them do this. Staff said this area of training had been updated recently. The medication records were looked at. Where there had been new drugs prescribed staff had made handwritten entries but not signed them. For one person there had been a change in the doses and timings of a medication but staff had added the information to the existing instructions rather than make a new entry showing clearly when and what changes had been made. The manager said that this would be dealt with straight away. She has got a copy of the October 2007 Royal Pharmaceutical Society guidance ‘Handling medication in social care settings.’ The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 13 One person looks after their own medications with help from their friends and not from staff. A risk assessment and agreement about this was seen in the care plan. Staff were seen using the hoist to transfer a female resident from the wheelchair to an armchair. They did not take into account the fact the individual was wearing a dress. The positioning of the straps for the sling meant that the person’s dignity was not maintained. The manager addressed this straight away and staff now make sure that peoples legs are covered so that their dignity is protected. Information from a healthcare professionals survey said that sometimes staff took them to see the person they were visiting in the communal areas rather than going to the privacy of their own rooms. The manager has investigated this and staff reassured her that all people are taken to a private area or to their rooms so that they can be seen in private. Information from people living in the home, their relatives and from surveys returned said: • They were kept up to date about changes in people’s condition, for example if they became ill or had an accident. • They knew about hospital appointments and would go with their relatives. • The care and support provided was as expected and they were happy the services provided by the home. • Staff help people to maintain their well being in a calm and supportive environment. • One person said that ‘The staff’s commitment to the dignity and individuality of residents is admirable.’ The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 14 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People exercise choice and control over their lives and maintain contacts with family and friends. The range of social and leisure activities available has increased and people enjoy the meals provided. EVIDENCE: Visitors said that they were made welcome when they visited and that staff would offer them a cup of tea. There was a good atmosphere in the home and it was clear that there were good relationships between staff, people living in the home and their visitors. It was clear that people could exercise choice and 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. Some people were helped to maintain links with people and organisations outside of the home. For example one person was taken to ‘D Day veterans’ meetings that they had attended before coming to live at the home. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 15 In the AQAA the manager said ‘We have recruited an activities co-ordinator and increased the number of activities in the home. The introduction of the Menu Master helps us to ensure the menu meets the nutritional needs of the residents. We have started the organisations Night Bite system to ensure that food and snacks are available 24 hours a day.’ During the visit this information was found to be correct. The provision of activities in the home was discussed at a residents/relatives meeting in August 2007 and all present agreed they were satisfied generally and discussed what more could be done. A part time activities coordinator has now been appointed and there is a regular programme of events in the home and trips out. On the day of the visit a group of people went out after lunch on a shopping trip. A new chef has been employed since the last inspection. They have worked in care homes before and have experience and knowledge about catering for older people and enriching meals. The kitchens were clean and well organised and the most recent inspection by the Environmental Health Department had been good. The chef is enthusiastic about making sure that people have access to snacks and drinks whenever they want them. They said they would be making sure there would be jugs of cold drinks available in all communal areas as well the rooms of people who chose to stay in their rooms. After lunch they were giving out drinks and crisps to people in the lounges which was much appreciated by all. This is good practice and all staff need to be involved with promoting and doing this. Information from people living in the home, their relatives and returned surveys said that: • The food was good and they enjoyed their meals. • People appreciated the multidenominational worship service that was held every week. • There were usually activiites that people could join in with. • Some people thought that there could be more social stimualtion and that it would be nice if staff had more time to spend with people, especially those who stayed in their rooms. • There were planned activites four afternoons each week and Tuesday was the ‘trip to the hardressers’ day. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their concerns will be listened to, taken seriously and acted upon. Staff are trained to protect people from abuse. EVIDENCE: Adult protection procedures are in place, including a copy of those produced by the local authority. The manager has attended a two day course about adult protection for care home managers that was provided by the local authority adult protection unit. Most of the staff have had training about abuse and adult protection but staff employed since the last inspection still need to do it. The manager said that plans were in place to provide it. Staff said that they would not hesitate to report actual or suspected abuse. The complaints procedure is displayed in the reception area and included in the information files kept in each resident’s room. The procedure is clear and easy to follow. Leaflets encouraging people make to suggestions and give feedback about services provided in the home were seen. The AQAA said that there is a clearly defined company complaints policy with agreed timescales for managing complaints. It has a three tier framework that includes the home, the regional management team and the national Quality and Compliance department. Records of all complaints received and dealt with are kept. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 17 There have been five complaints since the last inspection, three of which were forwarded to the home by CSCI. The concerns were about maintenance issues such as the nurse call system not working properly, TV reception, repairing a toilet, low staffing levels, low number of permanent staff, poor meals and poor supervision of somebody with memory problems as they left the home without staff knowing. All complaints had been looked into and responses sent to the complainant by either the manager or the home’s operations manager. Where necessary action was taken to carry out repairs. In addition the home made two referrals to the adult protection unit when they identified that people living in the home might be at risk from poor practice by staff. With the agreement of the adult protection team the organisation investigated and dealt with the concerns and appropriate action was taken to safeguard people living in the home. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 18 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, 20, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, tidy and well-maintained home that is suitable for their needs. EVIDENCE: The home appeared well maintained. The home has a handy/maintenance person for twenty hours a week who will do minor repairs and some safety checks, such as checking hot water outlet temperatures. The manager said that most of the works from the last fire safety report in May 2006 had been completed apart from making more ‘sub-compartments’. The decision not to do this had been taken by the organisation’s ‘estates’ department. A fire safety officer has visited the home recently and carried out a full fire safety survey. The manager had not received a copy of the report at the time of the visit. She said this would be forwarded to the ‘estates’ department so that plans for any work still to be done could be put in place. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 19 The AQAA said that there is a continued decoration programme. Since the last inspection the windows in the lounges have been replaced, one bathroom and some bedrooms have been redecorated. The gardens have been improved and with the help of fundraising by staff and relatives and work from staff and a person living in the home who loves gardening – the home now has a ‘sensory garden’ that can be enjoyed by all when weather permits. People living in the home said that they were happy with their rooms and that they were kept clean and tidy. It was clear that they could bring in their own furniture if the room was suitable as well as other belongings to personalise the room and make it their own. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are not always enough suitably trained staff on duty to meet peoples needs. EVIDENCE: Since the last inspection in November 2006 there have been a number of complaints about low staffing levels in the home. Information received from surveys said that: • The home was often short staffed. • People were rushed when staff were providing care because they had to get to the next person. • People were aware there were staffing problems and there had been a high staff turnover. • The staff are very kind and caring and work hard but there are times when there are not enough of them. On the first day of the visit there were twenty-three people in the home and four staff providing care and support to people in the morning. The manager said that the home worked to having four staff in the mornings, three in the afternoon/evening and two at night and that the organisation had said these numbers were adequate for the needs and numbers of people living in the home. She said that the times when the home had been short staffed were due to staff absences with little or no notice and staff had not been able to cover The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 21 the shifts. She said that all staff knew to contact her if a shift could not be covered and they could then contact an agency and request cover from them. Copies of the staff rotas showed that over the last four weeks there had been many occasions when there had been only three staff in the mornings and two staff afternoon/evening. When I was leaving the home at 6pm the care staff were looking at staff rotas and making phone calls to get cover for the night shift because the regular person was on leave and the shift had not been covered. The manager said she had asked them to do this as she was leaving the home because the shift had not been covered. Staff covered the night shift amongst themselves and the next day for the person who was coming in to do the night. Staff did not know what they were working after 1 November, as rotas had not been done. I rang the home on 29 October and new staff rotas were still not available, they were faxed to me on 30 October. The manager said the rotas were not done too far in advance because while they were recruiting new staff there were a lot of shifts that needed covering and it was daunting for people to look three weeks ahead and see if they could work extra shifts. She said new staff had been employed and staffing levels would be more consistent. The records for two people employed this year were looked at. They showed that pre employment checks, including Criminal Records Bureau Disclosures and two satisfactory written references were in place before employment was offered. They had started the organisation’s induction course that is equivalent to the Skills for Care common induction standards. Information about training was received before the visit. This showed that there are still gaps in training provided to staff. They have not all received appropriate training to help them maintain the health, safety and well being of people living in the home or themselves. The manager has identified this and plans have been put in place to make sure it is provided. In October 2007 training was provided about fire safety, moving and handling, Parkinson’s disease, dementia, dealing with challenging behaviour and pressure area care. During November staff will be enrolled on a distance-learning course about infection control and in December training will be provided about the mental Capacity Act. The manager has made links with other homes in the organisation so that staff can attend training sessions held in these homes. Ten out of the twenty care staff employed have achieved a qualification equivalent to NVQ level or higher. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed and run in the best interests of people living there. There is room for improvement especially around systems of communication between people, staff and the manager. EVIDENCE: The manager started working at the home early this year, after the last inspection. She is a registered nurse and this is her first management position. She has made application to become registered with the CSCI. She has completed the registered managers award and is waiting for her course work to be verified and to know if it has been completed successfully. She is the third manager in four years; therefore there has been little continuity in the way the home has been operated. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 23 It has been a difficult time since she started. Changes have been made to working routines and there has been some opposition to ‘changing the culture’ of the home; for example altering systems of working so that they are better for people living in the home. Information received before and during the visit raised some concerns about communication systems in the home. A visiting healthcare professional was concerned that staff were not passing on information at shift handovers. Feedback from one staff survey said that the manager was ‘given a hard time’ but she needed to know more about what was happening on a day-to-day basis. Some people thought that the manager ‘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 fact that the manager had not known that the night shift had not been covered until she was going home was of concern and highlighted the need for her to be ‘in touch’ with what is happening in the home. A deputy manager has been appointed to work with the manager and care staff to improve standards and promote team working. Training and support to help her with this is being arranged. The last quality assurance survey was carried out in December 2006. The people who responded were satisfied overall with the services provided. They had said that more activities could be provided and this is being dealt with. The outcomes of the survey were discussed at a ‘residents and relatives’ meeting and are on the notice board in the reception area. The responsible individual visits the home at least once a month and reports about the visits are sent to the CSCI. People living in the home and staff are spoken to find out what their views are and appropriate action taken if any issues are identified. The outcomes of these visits show that overall people are happy with the care and support they receive. The home does not look after resident’s finances. The administrator will look after small amounts of personal allowances brought in so that residents can have access to money at any time. This money is banked in interest bearing accounts and appropriate records are kept of all monies received and returned to residents. Information provided in the AQAA said that maintenance and safety checks of electrical and gas appliances were up to date. Accident records are kept. Staff add information to them about the accident and who last saw the person before the accident. The records looked at showed that appropriate action was taken as needed, such as calling ‘999’ or requesting a visit from the GP or district nurse. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 24 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 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 3 X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 25 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 OP8 Regulation Requirement Timescale for action 31/12/07 12, 13, 14 The manager must make sure that where risk assessments identify people as being at risk of falling, developing pressure sores or losing weight organisational guidance that has been produced is followed, advice is sought from appropriate health care professionals and detailed care plans put in place. This will make sure that peoples healthcare needs are identified and met. 23(4)(4a) The registered person must make sure that any works needed to meet fire safety requirements are carried out within the timescales agreed with the fire safety officers. The manager must make sure that there are enough staff on duty at all times to meet the needs and numbers of people living in the home. This must take into account peoples specialist care needs, physical and psychological needs as well as the size and layout of the DS0000001239.V345263.R01.S.doc 2. OP19 30/03/08 3. OP27 18(1)(a) 31/12/07 The Borrins Version 5.2 Page 26 building. 4. OP30 18(1)(c) (i) The manager must make sure 30/03/08 that staff receive appropriate training that helps them to maintain the health, safety and well being of people living in the home and themselves. It must also equip them to meet people’s personal, health and social care needs, including specialist health care needs. (Previous timescales of 31/07/06 and 30/04/07 have not been met.) 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 OP7 Good Practice Recommendations The manager should make sure that detailed care plans are in place for all of an individuals identified needs so that staff have guidance about what they are and how to meet them. The manager should make sure that additions and changes to peoples medication administration records are dated and signed by the person making them. This will protect people and reduce the risk of errors. The registered person should take steps to make sure that staff take steps to protect peoples dignity when moving them from one place to another. In order to protect people living in the home the registered person should make sure that adult protection and abuse awareness training is provided to the staff who have not yet had it. The manager should make sure that she completes the registration process with the Commission. DS0000001239.V345263.R01.S.doc Version 5.2 Page 27 2. OP9 3. OP10 4. OP18 5. OP31 The Borrins 6. RCN The manager should look at ways of improving communication systems in the home and making sure that she is touch with what is happening on a day-to-day basis. The Borrins DS0000001239.V345263.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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.V345263.R01.S.doc Version 5.2 Page 29 - 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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