Inspection on 07/11/06 for The Borrins

This inspection was carried out on 7th November 2006.

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 26/10/07

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 Key Unannounced Inspection 09:30 7th November 2006 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.V307512.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.V307512.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) 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.V307512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 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 £344.75 per week to £620. Items not covered by the fee include newspapers, hairdressing and chiropody. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two visits were made on 7th and 13th November 2006. The home did not know that this was going to happen. Feedback was given to the manager at the end of the visits. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents and to see what progress had been made meeting requirements in place from the last inspection. Before visiting the home the inspector asked for information from the manager which included asking about what policies and procedures in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Comment cards were sent to the home to be given to residents, their relatives and other visitors to find out what their views of the home were. The views of doctors and district nurses who visit the home were also asked for. At the time of writing this report five resident, two relatives and two doctors responses had been returned. In order to find out how well staff knew residents care plans were looked at during the visit and residents, visitors and staff were spoken to. Other records in the home were looked at such as staff files, complaints and accidents records. 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 well maintained and decorated and furnished to a good standard. Residents said that they can bring in their own belongings to personalise their rooms and that the home was always clean tidy and did not smell. They said that the food was good. Visitors said that they could visit the home at any time, that they were made welcome and were offered refreshments by staff. This makes it a pleasant, comfortable and homely place to live. Relationships between staff and residents were warm and friendly. Residents said that the staff were kind, caring and attentive. They said that they can choose how and where to spend to their time and whether or not they want to join in with the planned social activities. There is a regular programme of activities, which includes bingo, craft sessions and trips out, for example to ‘Harry Ramsdens’ for fish and chips. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 6 Visiting district nurses said that they were called in appropriately in order to meet resident’s healthcare needs and that they could see the residents in the privacy of their own rooms. This shows that resident’s privacy is respected. What has improved since the last inspection? What they could do better: The three requirements in place after the last inspection have not been met. A new manager started at the home in April 2006 and has now had time to get to know the home, the residents and staff. Time must now be spent on making sure that action is taken to meet the shortfalls identified in this report. Areas that must be made a priority because of the potential to affect the well being of residents are: * Making sure that enough information is taken about potential residents needs so that an informed decision about whether or not the home and the skills of the staff can meet them. * Getting more information, especially from residents and their relatives, about individuals needs, strengths, likes and dislikes to put together a detailed care plan which will give staff clear guidance about the care to be given to individuals. * Making sure that the staff receive training, which helps them to recognise, when residents health and physical care needs are changing. This will help them to know when to request support and advice from other healthcare professionals. * Staff must be aware of their responsibilities when dealing with medicines and make sure that safe practice is always followed * Information about complaints could be kept in a way that would help people to learn from them, avoid them in future and improve services provided to residents. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 7 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 DS0000001239.V307512.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.V307512.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. Standard 6 does not apply to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a risk that residents will be admitted whose needs cannot be met because they are not fully identified before admission. EVIDENCE: Information for residents and visitors is available in the reception area. Files of useful information are placed in every bedroom. The information in the Service User Guide was much clearer and easier to understand than the Statement of Purpose. It tells the reader clearly what services are provided in the home. The Statement of Purpose has been produced on a company template. It uses technical jargon and makes references to company policies that mean nothing to people outside of the organisation. This document should be reader friendly and in plain English. The manager was advised to look at guidance available on the CSCI website. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 10 Residents and visitors said that they received enough information about the home when they came to look round and they were offered a trial visit. One said that they had liked the ‘look and feel of the home’ and that was why they had chosen it. Staff visit potential residents to assess their needs before they come to live at the home. Information gained from these visits is recorded on an initial assessment form. The level of detail varied and it was clear that they were not being used to identify whether or not the home could meet the individual s needs. The records for one resident did not show that their main reason for needing 24 hour care was because they had dementia. The home is not registered to admit people with dementia. Staff said that they were able to meet their needs and that they had had a one day course about dementia. But this had not fully equipped them to meet this individuals needs. They had not received any training about dealing with challenging behaviour. Another resident’s records showed that the only pre admission information was a copy of the local authority care needs assessment that had been carried out some months before they were admitted. The manager was advised to make sure that these are up to date at the point of moving in as individuals needs can change a lot in a short time. The Borrins DS0000001239.V307512.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 at least once during a 12 month period. 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. There is a risk that residents care needs will not be met because there is not enough guidance and information fro staff in the care plans. Some of the practices when dealing with medications increase the risk of mistakes being made. EVIDENCE: When talking to staff it was clear they had a good understanding of individual’s personal care needs and what their preferences were, but this was not seen in the care plans. Three care plans were looked at. These did not provide staff with detailed guidance about how to meet individuals identified needs. Examples where appropriate guidance was missing included: - The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 12 * A resident with a pressure sore. The district nurse was seeing them and a specialist pressure-relieving mattress had been provided but there was no care plan telling staff what type of mattress it was or how to use it properly. There was no information about how often position changes should be carried out or where this information was to be recorded. * A resident who had fallen before being admitted to the home had been assessed as at medium risk of falls. They had fallen four times since August 2006 but there was no evidence to show that the advice and support of the falls prevention team had been sought. The manager said this had been done when feedback was given at the end of the inspection. * Two residents with dementia did not have any information in their care plans about how the dementia affected them and what staff could do to help them. * A resident had become doubly incontinent since being admitted. The care plan had not been reviewed and said that they wore a pad at night only. * A moving and handling assessment had been done in August 2005 and not reviewed until October 2006. By this time the resident’s needs had changed so much a new assessment should have been done but instead comments were added to the original document. There was no guidance for staff about how to move them safely or what equipment to use. The care plan about their mobility had not been altered to show they were now immobile. * For residents at risk of losing weight or not drinking enough records of their food and fluid intake were not kept. Staff said this information was in the daily records but these not been completed every day and the detail about food and fluid intake varied greatly. Sometimes there were gaps of three and more days between entries in the document titled ‘daily record’. Two of the plans did not show that the resident or their relatives had been involved with the care planning process. Monthly reviews/evaluations had not been carried out; one care plan had not been evaluated since August 2006. Feedback from healthcare professionals who visit the home were positive. GP’s and district nurses said that they were called out appropriately and that staff worked with them and followed instructions and guidance left for them. One said that more information when requests for help were made would be useful. Feedback from residents was good and said that: * They received the help and support they needed including medical help. * Staff were kind and caring and would listen and act on what they said to them. * Staff respected their privacy and that they always knocked on door before entering bedrooms. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 13 The home has just started to use a new chemist to supply medication and staff are getting used to using a blister pack style monitored dosage system. The manager orders repeat prescriptions. She said that all prescriptions come back to the home to be checked before they are sent to the chemist. The medication administration records (MAR’S) are used to record all items received into the home. Any drugs not used are returned to the chemist and records are kept in a separate book. The MAR’S seen were fully completed. But on checking the medication trolley and storage cupboards some problems were found: * One of the blister packs of tablets had a handwritten label with the residents name and when the tablets were to be given. But there was no information about what the tablet was, when and how many had been dispensed. Staff had been giving it and signing for a tablet that they assumed it to be. This is not safe practice. * A resident admitted for respite care had brought some tablets in with them that had been put into another container with three chemists labels on it, all with different dates. Staff had put this container in the trolley to use. They were told that it is not safe to administer tablets from any container other than the original one used by the dispensing chemist. *The controlled drugs records for one resident’s slow release painkiller patches that are changed every three days showed that one dose had been missed, dates had been altered and another dose may have been given but there was no written entry to prove it. The manager was made aware of these discrepancies and said she would deal with it. * Not all bottles of eye drops in use had dispensing labels attached to the bottles and none of them had been dated with the day that they had been put into use. Senior care staff are responsible for giving medications to residents. They said that they received training as part of the senior carer preparation course and some of them had attended training arranged by the new chemist, which had been very interesting. The manager was advised to make sure that any training given equipped staff to deal with medications safely. The Borrins DS0000001239.V307512.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 at least once during a 12 month period. 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. Residents keep contact with family and friends and choose how and where to spend their time. 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, residents and visitors. The home is advertising for an activities organiser and until that time the administrator has put together a diary of planned events. This was displayed in the reception area and included in-house events like bingo and film afternoons, trips out, entertainers coming in, the mobile library comes every three weeks and transport can be arranged to take people to church if they want to go. During the visits to the home residents were taken out to ‘Harry Ramsden’s’ for a fish and chip lunch, an afternoon was spent making cards and reminiscing and there was party to celebrate a residents birthday. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 15 Feedback from residents said that they were happy with the arranged activities, some said they would like more. One said that poor eyesight affected what they could join with. It was clear that residents were able to 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 and they could choose where to eat their meals. The kitchens were clean, tidy and well organised. A four week menu is being followed and copies were displayed in the reception area and in the information file. At mealtimes the tables were set attractively, the meals were nicely presented and looked very appetising. Residents said that they enjoyed the meals, the food was very good, they were given choices and offered alternatives. The Borrins DS0000001239.V307512.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 inspected at least once during a 12 month period. 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. Residents are safe but the systems for recording complaints and concerns are not accurate. There is a risk that appropriate action may not be taken to improve services when shortfalls are identified through complaints made. EVIDENCE: Adult protection procedures are in place, including a copy of those produced by the local authority. Not all staff have had training about abuse and adult protection yet. The manager said that plans were in place to provide it. Staff said that they would not hesitate to report actual or suspected abuse. Residents said that they felt safe. 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 suggestions and give feedback about services provided in the home were seen. The PIQ said that three complaints had been received since the last inspection. The complaints record was not up to date and did not contain details about complaints and concerns that had been sent direct to the CSCI and referred back to the provider to investigate. The manager said that this information was being kept elsewhere. Information from reports sent to the CSCI by the responsible individual have shown that they have been proactive in dealing The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 17 with and investigating issues when they have been found, for examples two instances where medication errors have been reported. Where other issues affecting resident well being were identified the adult protection unit was contacted for advice and support, which is good practice. But this information was not in the complaints file. A record of all complaints and concerns received and details of any investigations made and what the outcomes where must be kept. This will help the home to audit complaints and identify where improvements or changes need to be made. The Borrins DS0000001239.V307512.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and comfortable home. EVIDENCE: The home appeared well maintained. The home does not have a handy/maintenance person and has the services of one from another home in the group while they recruit somebody. Records for checking hot water temperatures and other safety checks were up to date. A visitor said that sometimes light bulbs were not replaced straightaway and this was a problem for people with poor eyesight. The manager said she would make sure that alternative lighting would be available. The last fire safety officer’s visit was in May 2006. A copy of this was sent to the CSCI, which said that the home had agreed to complete listed work by May 2007. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 19 The PIQ said that there have been no changes to the buildings but that a patio area has been added in the garden. Feedback from residents’ surveys said that they had enjoyed using this in the warmer weather. Information from the PIQ and reports from the operations manager said that there is an ongoing programme of maintenance and decoration. Since the last inspection four bedrooms and one of the bathrooms have been redecorated. The manager said that other bedrooms are due to be redecorated and the carpet in a particular bedroom was to be replaced because of an odour problem. Residents 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.V307512.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 at least once during a 12 month period. 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 enough staff on duty but the training given has not equipped them to always be able to recognise when resident’s healthcare needs are changing. There is a risk that some healthcare needs may be overlooked. EVIDENCE: When talking to staff during the site visit they said that they worked in a residential home and were not trained the same as staff in a nursing home would be. Information about training from talking to staff, the PIQ and records kept showed that not all had received training which helped them to monitor and maintain the health, safety and well being of residents or themselves or to meet residents specialist care needs. Examples of training not given included infection control, dealing with challenging behaviours, further training around meeting needs of people with dementia, pressure area care, general health care, diabetes, stroke awareness and about Parkinson’s disease. The manager said that all staff were now enrolled on a distance learning health and safety course and plans were in place to increase training provision. The manager and staff were made aware that they must receive training which helps them to recognise when residents health and physical care needs are changing so that they will know when to request support and advice from other The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 21 healthcare professionals. Examples where this would have been useful were given and included where a resident had not been drinking enough but this had not been recognised and staff waited for the next planned GP visit rather than asking for one earlier. The resident became dehydrated and needed to be admitted to hospital. Copies of staff rotas sent with the PIQ showed that numbers of staff on duty had been increased. Staff said that this was much better as they now felt they had more time help residents meet personal and social care needs without rushing them. Feedback from residents and visitors said that there were usually enough staff available. Three staff files were looked at. These showed that: * Application forms including health check questionnaires were completed. But the forms must be amended to request a full employment history and ask for reasons for any gaps in employment. * Two satisfactory written references were in place before employment was offered. * Confirmation of satisfactory POVA (Protection of Vulnerable Adults) was in place before employment was offered and enhanced CRB (Criminal Records Bureau) checks were in place. * Proof of identity was seen. The PIQ said that good progress was being made towards 50 of care staff being qualified to NVQ (National Vocational Qualification) level 2 or higher. Eight staff out of eighteen now have this qualification and are more are going to start doing it. The Borrins DS0000001239.V307512.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. 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 residents but there are areas where improvements need to be made which will increase the quality of care provided. EVIDENCE: The manager has been working at the home since late April 2006. She has had experience of managing a care home and has successfully completed the registered managers award with a local college. She has applied to the CSCI to be recognised as the registered manager. The report from last years care home survey was on the notice board in the reception. This showed that overall people were satisfied. Comments had been made about increasing activities and providing a walkway round the building. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 23 The manager said that these had been acted upon and were the reasons why the garden areas had been improved and an activities coordinator was being recruited. The survey forms for this year have been sent out and they will be returned to head office who collate the results and publish the report. The responsible individual visits the home at least once a month and produces detailed, informative reports. Copies are sent to the CSCI. Residents and staff are spoken to find out what their views are and appropriate action taken if any issues are identified. The manager had meetings with staff, the last full staff meeting was in August 2006. Since then smaller meetings with either senior carers, domestic and kitchen staff have been held to discuss issues specific to their job. A resident’s newsletter was produced in October 2006 and gave details of planned events and those that had taken place. The last residents’ meeting was in April 2006. The manager said that one would be arranged in the near future. Residents and visitors said that they were able to talk to the manager or senior staff at any time and were kept up to date with changes. Fire safety systems checks were up to date. The senior in charge tests the fire alarms every Tuesday. Fire safety training has been given to all staff within the last six months. The PIQ had not been fully completed and did not have dates for all maintenance checks, for example when the hoists were serviced and the date of the electrical wiring safety check. The manager was asked to forward this information. The accident records are kept altogether in one file. The records did not say what time the resident had last been seen before the accident or by who. The individual accident reports for each month were kept in a plastic wallet. There was no index and it was not clear if the information was being audited or monitored. One resident had fallen three times in September but there was no information as to what action had been taken to reduce the risk of falling other than to monitor or supervise them when walking. There was nothing to show that advice from the falls prevention team had been asked for. The manager said that if a resident is found on the floor staff have been told that unless the resident can get themselves up from the floor they must ring for an ambulance. 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 The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 24 accounts and appropriate records are kept of all monies received and returned to residents. The manager has just completed giving all staff formal supervision 1 to 1 sessions. She has not received any formal training to do this. Talking about what she has done showed that she is following good practice and talks to staff about progress made, work issues and training needs. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 3 X 3 The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement The pre admission assessments must be detailed and provide enough information for the home to decide if the individuals needs can be met. The registered person must make sure that the homes registration categories are taken into consideration when looking at admitting new residents. The registered person must make sure that staff receive appropopriate training in order to meet specialist care needs of residents. The care plans must be more detailed and clearly show how an individual residents personal, physical, health and social care needs are to be met. Timescale for action 31/12/06 2. OP4 14 31/03/07 3. OP7 14, 15 31/03/07 4. OP8 (The timescale for meeting this requirement was extended from 31/3/06 to 31/07/06 and has not been met.) 12, 13, 14 The registered person must 31/03/07 make sure that appropriate risk assessments are carried out for DS0000001239.V307512.R01.S.doc Version 5.2 Page 27 The Borrins residents at risk of falling, developing pressure sores or losing weight. Detailed care plans must be put in place and appropriate records kept. The manager must seek advice from the district nurses, the falls prevention team and other healthcare professionals in a timely manner. (The timescale of 31/03/06 has not been met.) The manager must make sure that systems for dealing with medications are safe and protect residents and that staff are appropriately trained and aware of their responsibilities. The manager must make sure that records are kept of all concerns and complaints received and what action was taken to deal with them. The manager must make sure that at least 50 of care staff have a qualification equivalent to NVQ 2. The manager must make sure that: * Staff receive training which helps them to recognise when residents healthcare needs are changing so that the advice and support of appropriate healthcare professionals can be sought. * Staff receive appropriate training in order to meet the specialist needs of residents. Particular regard must be paid to providing training around dementia and dealing with challenging behaviours. (The timescale of 31/07/06 has The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 28 5. OP9 13 31/12/06 6. OP16 22 31/12/06 7. OP28 18 31/12/07 8. OP30 18 30/04/07 9. OP31 9 not been met.) The manager must complete the registration process with the Commission. 31/01/07 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. 5. 6. Refer to Standard OP1 OP7 OP18 OP28 OP29 OP38 Good Practice Recommendations The Statement of Purpose should be revised in order to make sure that it is in plain English and reader friendly. The daily record forms should be completed daily.(This recommendation was first made May 2005.) The manager should make sure that adult protection and abuse awareness training is provided to the staff who have not yet had it. The registered person should ensure that at least 50 of care staff achieve NVQ level 2. The application forms should be revised in order to request a full employment history and identify the reasons for any gaps in employment. The manager should make sure that the information requested in the PIQ is sent to the Commission. The information in the accident records should include details as to when the accident victim was last seen and by whom before the accident happened. Accident records should be monitored and audited regularly so that any trends can be identified and appropriate advice sought from relevant healthcare professionals. The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Borrins DS0000001239.V307512.R01.S.doc Version 5.2 Page 30 - 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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