CARE HOMES FOR OLDER PEOPLE
The Borrins Station Road Baildon Shipley BD17 6NW Lead Inspector
Nadia Jejna Unannounced 30 MAY 2005 at 11:30 AM
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service The Borrins Address Station Road Baildon Shipley BD17 6NW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 582604 01274 598066 Bupa Mrs T Jagger Care home 32 Category(ies) of Physical disability - over 65 (4) Old age(28) registration, with number of places The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 2nd December 2004 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 local amenities. The building is a period property which has been adapted to its purpose while retaining many of its characteristics. It stands in its own grounds and car parking is available. The gardens are well maintained and accessible to service users. Some of the double rooms are being used as singles which means that the homes maximum occupancy level is 28. Communal facilities include 2 lounge areas and a dining area. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was announced and took place on the 2nd December 2005. There have been no further inspections until this unannounced inspection. The people who live in the home prefer the term residents, and this is the term that will be used throughout this report. The purpose of this inspection was to monitor the home’s progress since the last inspection and to assess whether the care given to residents meets minimum standards. During the inspection records were examined, some areas of the home were seen, such as bedrooms, lounges and bathrooms; care staff were observed carrying out their work, and discussions, both on an individual and joint basis, were held with two members of staff, the manager, three visitor, and seven of the residents. Survey cards were left at the home for residents and their relatives or visitors to complete and return to the Commission for Social Care Inspection (CSCI). The inspection started at 11:30 and ended at 18:00 on the 30th May 2005. What the service does well:
Care is provided in a clean and well-maintained building. Residents said that the staff are kind, caring, attentive and that they respond quickly to requests for help and when answering call bells. One of the residents said that there have been some positive changes made since the manager came to the home and that it was well organised. Visitors said that they are able to visit the home at any time, that they are made to feel welcome and are offered refreshments by staff. One visitor said that they are made to feel ‘part of the family’ and that they are encouraged to join in with planned social activities. Care staff said that they enjoyed working at the home because they felt that they provided good standards of care to the residents and that they worked well together as a team. One carer described the home like a jigsaw, in that all the pieces fit together well and it means a good outcome for the residents. Relationships between staff and residents were warm and friendly. Staff were polite and respectful and that they were anticipating resident’s needs. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 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. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 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 standard(s) 1, 3, 4 and 5 Residents can make an informed choice to move to the home through trial visits and information provided. The home ensures that it can meet the needs of prospective residents before they are admitted. EVIDENCE: A resident who had been in the home for only five days said that they had chosen to be there after making trial visits to a number of homes in the area. They had been given a copy of the Service User Guide at the trial visit. They said that they had been made to feel very welcome and that they already felt settled. Another resident had been unable to visit the home but their relatives had and they discussed the choices before any decisions were made. The manager was very clear about the homes registration categories and the needs that it can meet. She said that if a residents needs changed to the point that they could no longer be safely met in the home, a full review would be held involving the resident, their relatives and their allocated social worker.
The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Residents care needs are met but this is not fully evidenced in the care plans. EVIDENCE: A care plan had not yet been completed for the most recently admitted resident. Information from the pre admission assessment was available and staff had identified her most immediate needs in the daily records. The manager was meeting with them that afternoon to discuss and plan their care. Two care plans were reviewed in detail. It was seen that staff have worked hard to ensure that all required information is in place. This must continue in order to ensure that clear and detailed person centred care plans are in place which clearly show how identified and assessed needs are to be met. Examples of resident’s needs that had not been included in the care plans were given to the manager. This included where a resident was at risk of developing pressure sores but there were no risk assessments or care plans in place for this. The information in the care plans was very generic and could apply to any of the residents in the home. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 10 The manager said that care plans are reviewed after the six week trial period. The resident, their relatives and the social worker are invited to attend but if the social worker does not come the review would go ahead. The daily record sheets were not completed on a daily basis. Residents are allowed to choose if they wish to self medicate and this is done within a risk assessment framework. The systems for monitoring stock levels of self-administered medications did not show how many tablets the residents had or how it being monitored that they were taking them correctly. Lockable facilities are provided in resident’s rooms. The manager said that staff administering medications have received some training in order to do so and that they will be enrolling on a distance learning certificated course in the near future. Residents said that they were well looked after and that their needs were met. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 14. Residents are encouraged to participate in social and leisure activities, to maintain links with their friends and family and to exercise choice and control over their lives. EVIDENCE: A weekly programme of planned activities is displayed in the reception area. Residents said that they enjoyed these and that they could choose whether or not they wanted to join in. They also said that they can choose how they wish to spend their day, what time to get up, go to bed and whether or not they want to be in their own rooms or the communal areas. One of the care plans contained an activity profile, which gave a good picture of the residents social and leisure interests. The stimulation and social well being care plan however did not back this up and could have related to anybody in the home. Visitors said that they could visit the home at any time, that they were always greeted politely, made to feel welcome and would be offered a choice of drinks. One of the visitors said that they felt as if they were part of the ‘family’, that relatives and visitors were encouraged to join in with and be part of planned activities. They gave examples of recent events that had been held to celebrate VE Day and ‘Red Nose’ day.
The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 12 The home does not yet have a dedicated activities organiser and the manager is hoping that one of the carers will specialise in this area when the home is fully staffed. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. Residents are protected and feel safe living in the home. Residents are aware of the complaints procedure and how to use it. EVIDENCE: The complaints procedure is displayed in the reception area and is included in the Service User Guide. Residents said that they knew what to do and who to speak to if they wanted to make a complaint. There has been one complaint since the last inspection, which was investigated by the operations manager and appropriate actions taken. Copies of adult protection procedures are in place, by the organisation and the local authority. The manager was very clear what actions to take in the event of suspected or actual abuse. Plans are in place to provide further abuse awareness training to staff. Care workers said that they were aware of the adult protection procedures and where they were kept. They said that they would have no hesitation in reporting suspected or actual abuse. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24 and 26. Residents are living in a clean, tidy, safe and well-maintained home, which is suitable for their needs. EVIDENCE: The building is well maintained and the home is clean and tidy. The communal areas have been redecorated to a good standard and residents said that they were pleased with this. New furnishings were on order and due to arrive in the very near future. The manager said that three of the bedrooms are due to be redecorated. Residents said that their rooms were kept clean and tidy and that their laundry is returned in good condition in reasonable time. It was seen that residents are encouraged to bring their own belongings to personalise their rooms. The manager has got a copy of the most recent fire safety report. She said that the maintenance person has dealt with those requirements that he is able to but that the larger works will have to be costed and planned by head office. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The home ensures that adequate numbers of staff are on duty in order to meet the needs of residents. Robust recruitment procedures are followed to protect residents. Staff receive appropriate training. EVIDENCE: Staffing levels were appropriate to the number and needs of residents in the home. The manager said that almost all positions are filled and that only one carers post remains vacant. Staffing levels are maintained by staff doing extra shifts. Agency staff are used if needed and in order to maintain continuity the manager requests the same staff to be supplied. The manager said that conformation has been received from the agency that staff supplied have undergone robust recruitment procedures and received appropriate training. Records for one recently employed care worker showed that all required information was maintained, two written references had been obtained and a satisfactory CRB and POVA check was in place. The care worker said that they were undergoing induction training and had already completed training in fire safety, moving and handling, health and safety and that they had work ‘shadowed’ an experienced care worker for one week. They said they were soon to start the TOPSS induction training course and they were hoping to do NVQ after this. Individual training records are maintained. These show that there is a positive commitment towards ensuring that staff receive training appropriate to the
The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 16 work they are to perform. Courses included infection control, food hygiene, and first aid. It was recommended that training around specialist needs that residents may have should also be provided. All senior carers have done a two day seniors training course. The manager said that 30 of staff now have NVQ 2 and that it is anticipated that 70 of staff will have this qualification by the end of 2005. The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 and 33. Residents are able to contribute to the running of the home by being consulted about their views and opinions of the service provided by the home regularly. EVIDENCE: Residents and visitors said that they felt comfortable approaching staff and that they were kept informed of changes. The manager said that residents and family meetings are held every three months. Letters are sent out to invite relatives and the agenda is planned at the beginning of the meeting. If relatives cannot attend they are invited to put forward any items that they would like to have discussed at the meeting. Survey questionnaires are sent out six monthly to residents and their relatives by head office. The completed forms are returned to them and they will collate the results and then send a copy to the home. A copy of the most recent survey was available and will be discussed at the next residents meeting.
The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 2 x x x x 2 x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x x x x The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 14, 15 Requirement Detailed, individual care plans must be put in place which clearly show how service users personal, physical, health and social care needs are to be met. The registered person must ensure that appropriate risk assessments are carried out for service users at risk of developing pressure sores. The registered person must forward an action plan detailing how recommendations made in the fire safety survey of March 2005 will be met. The registered person must ensure that bedrooms 18 and 20 are redecorated. (The timescale of 1.4.05 has not been met, it was agreed to extend this date to 31.10.05) The manager must achieve NVQ level 4 or equivalent by the agreed date of 31.12.05. ( This standard was not assessed and the requirement has been carried forward with the previously agreed timescale.) Timescale for action 31.12.05 2. 8 12, 13,14 31.12.05 3. 19 23 31.10.05 4. 24 23 31.10.05 5. 31 9 31.12.05 The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 20 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 7 8 9 28 Good Practice Recommendations The daily record forms should be completed daily. The registered person should ensure that continence assessments are carried out by appropriatly trained staff or the district nurses. Records should be kept. The systems for auditing and monotoring stock levels of medications should be extended to include medications kept by service users who self administer. The registered person should ensure that at least 50 of care staff achieve NVQ level 2 by 31.12.05 The Borrins J52 S1239 Borrins V226823 240505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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