CARE HOMES FOR OLDER PEOPLE
The Borrins Station Road Baildon Shipley West Yorkshire BD17 6NW Lead Inspector
Nadia Jejna Unannounced Inspection 10:30 8 December 2005 and 3 January 2006
th rd 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.V262748.R01.S.doc Version 5.0 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.V262748.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Borrins Address Station Road Baildon Shipley West Yorkshire BD17 6NW 01274 582604 01274 598066 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes (GL) Ltd Mrs Tracey Jagger 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.V262748.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th May 2005 Brief Description of the Service: The Borrins provides personal care without nursing for up to 32 people over the age of 65. Accommodation is provided in mainly single bedrooms. But 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 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. The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 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 unannounced and took place on the 30th May 2005. There have been no further inspections. 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 looked at, some areas of the home were seen, care staff were observed carrying out their work, and discussions were held with staff, the manager, residents and their visitors. The inspection was carried out over two days, 8th December 2005 from 10:30am to 3:30pm and 3rd January 2006 10:30 to 12:00. What the service does well: What has improved since the last inspection?
A new care plan format has been introduced which is based around person centred care. The plans seen showed that some improvements had been
The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 Page 6 made. They identified individual strengths, needs, what the expected outcome of the care plan was and what action/support was to be given by staff. Systems were in place to record and monitor the stock levels of medications received into the home and for those that were not used and returned to the pharmacy. Appropriate risk assessments had been carried out and signed agreements were in place for a resident who had chosen to self medicate. The manager has successfully completed a management training course equivalent to NVQ 4. 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 DS0000001239.V262748.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, 4 and 5 were met at the last inspection. Therefore none of these standards were assessed on this occasion. EVIDENCE: The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9. Residents care needs are met, but this is not yet seen clearly in the care plans. Residents are able to look after their own medications if they wish, supported and protected by the homes policies, procedures and risk assessments. EVIDENCE: Visiting district nurses said that they were called in appropriately in order to meet resident’s healthcare needs and that staff followed advice and instructions. The manager said that staff have been working hard to improve the information contained in the care plans. To help with this a new care plan format has been introduced which is based on person centred care. A key worker system has also been introduced. Two care plans were looked at. It was clear that some improvements had been made. They identified individual strengths, needs, what the expected outcome of the care plan was and what action/support was to be given by staff. However the daily report forms were not being completed on a daily basis. The manager said that staff would be told that this issue must be addressed.
The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 Page 10 One of the care plans showed that the resident had had a number of falls but there was no falls risk assessment in place or a plan to inform staff on how best to maintain the individuals safety. The manager should contact the falls prevention team for advice and support. Residents and their visitors said that they were involved in the care planning and review process. Senior care staff look after medication in the home. The home uses a monitored dosage system, which is delivered each week by the pharmacy. Systems were in place to record and monitor the stock levels of medications received into the home and for those that were not used and returned to the pharmacy. The medication records were fully completed and up to date. The manager said that they are all doing a certificated distance-learning course about the administration of medications. One resident prefers to look after their medications. Their care plan showed that appropriate risk assessments had been carried out and there was a signed agreement in place. The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 and 15. Residents’ choices are respected and contact with family and friends is encouraged. A good, varied and nutritious diet taking into account individual choices is provided. EVIDENCE: Residents said that they were happy living in the home and satisfied with the services provided. One said that they would not want to go anywhere else and that they had ‘good laughing times’ with the staff. Residents said that they could choose when to get up, go to bed and if they wanted to stay in their rooms or go in the lounges. Visitors said that they could visit at any time and that they were welcomed by friendly staff and were offered a drink. The care plans seen contained an activity profile, which showed individuals preferred leisure interests as well as personal likes and dislikes. This information is used for the social care plans. A weekly plan of social activities is displayed in the reception and other communal areas.
The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 Page 12 The menus are available in communal areas and written on a chalkboard in the dining room. The cook speaks to residents regularly and attends residents/relatives meetings in order to find out if they are satisfied with the meals provided and to discuss changes to the menus. A choice of meals is always provided and alternatives would be offered as needed. At lunchtime the meals were attractively presented and it was clear that residents choices were respected. The meal was relaxed and unhurried and residents were able to enjoy the meal at their own pace. Residents said that the food was good and they always had plenty to eat. The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 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 the following standard(s): Standards 16 and 18 were met at the last inspection. Therefore none of these standards were assessed on this occasion. EVIDENCE: The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26. Residents live a clean, tidy and well-maintained home, which is suitable for their needs. EVIDENCE: The home was clean and tidy. Residents said that their rooms were kept clean and that they appreciated this. The home is well maintained. The responsible individual said that plans were in place to deal with the recommendations made during the last fire safety officer’s visit in March 2005. The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 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 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): 28 and 30. Staff receive appropriate training. EVIDENCE: While talking to staff it became clear that some residents had developed dementia since being admitted to the home. Staff felt that they were meeting their needs but they would be better equipped if training around dementia was made available to them. The manager said that this topic would be added to the training programme. The manager said that 4 staff have already achieved NVQ level 2 and that 5 are working towards it. It is anticipated that that 50 of staff will have this qualification within the next six months. The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 Page 16 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, 35 and 38. The home is managed and run in the best interests of the residents, they are consulted regularly and their opinions are valued. EVIDENCE: The manager has successfully completed a management training course equivalent to NVQ 4. The manager often works as a senior carer. While this is good practice for developing relationships with residents it does reduce the time available for fulfilling her managerial responsibilities. Consideration should be paid to recruiting a deputy manager for the home. Residents/relatives meetings are held regularly, as are staff meetings. Records and minutes are kept. From discussions with the manager, staff, residents and visitors it was clear that the home is managed and run in the best interests of the residents and that their opinions are valued.
The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 Page 17 The administrator looks after any monies that are held in safekeeping for residents. Appropriate records are kept. The home does not act as agent or appointee for any residents and asks that relatives deal with finances if the residents cannot do it themselves. Accident record/report forms are completed but some of these are filed before the manager sees them. Systems should be put in place to make sure that they are seen and audited so that appropriate action can be taken, particularly for residents who have frequent falls. The manager completed a questionnaire, which said that maintenance and safety checks were carried out on the homes equipment and installations, including the gas appliances, boilers and central heating system as well the lift, moving and handling equipment and the call system. The handyman is responsible for the weekly fire safety system testing. Records are kept. He has received training in order to provide staff with regular fire safety training. Health and safety audits are carried out at regular intervals by the organisation. The manager is working through the action plan put in place after the last one, which was 18 months ago. Records were seen which showed that most staff in the home have received training in order to maintain the health, safety and well being of residents and themselves. The manager said that arrangements are in place to make sure that all staff receive this training and updates as required. The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 X X 3 X X 3 The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 Page 19 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 OP7 Regulation 14, 15 Requirement Timescale for action 31/07/06 2. OP8 3 OP30 Detailed, individual care plans must be put in place that clearly show how service users personal, physical, health and social care needs are to be met. (It was agreed to extend this timescale.) 12, 13, 14 The registered person must ensure that appropriate risk assessments are carried out for residents at risk of falling. The manager must seek advice from the district nurses and falls prevention team. 18 The manager must make sure that staff receive appropriate training in order to meet the specialist needs of residents. Particular regard must be paid to providing training around dementia. 31/03/06 31/07/06 The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 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 Refer to Standard OP7 OP28 OP31 Good Practice Recommendations The daily record forms should be completed daily.(This recommendation was first made May 2005.) The registered person should ensure that at least 50 of care staff achieve NVQ level 2. The responsible individual should consider recruiting a deputy who will enable the manager to spend more time on managerial responsibilities. The Borrins DS0000001239.V262748.R01.S.doc Version 5.0 Page 21 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
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