Care Home: The Borrins

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What the care home does well The home is well managed and people are consulted about how they want their care and support to be provided. The manager has an open door policy and encourages people to tell her what they think about the service. There are regular meetings arranged for people living at the home and their relatives and there are recognised quality assurance monitoring systems in place. There is good and friendly interaction between the people who live at the home and staff and people are encouraged to make choices and decisions about how they want to spend their time while living there. The Borrins DS0000001239.V378332.R01.S.doc Version 5.2 The home has established close working relationships with other health care professional to make sure people`s health care needs are met and they have access to the full range of NHS services. The chef is knowledgeable about people`s particular likes and dislikes and any special diets they need, and makes every effort to give people the foods they will enjoy. A thorough staff recruitment and selection procedure and a commitment to staff training makes sure that people that use the service are cared for and supported by staff that are suitable to work in the caring profession. Comments from people living at the home and/or their relatives included the following "the home is well managed and the staff are kind and caring" and “the food is good and plentiful and the rooms are clean and tidy.” What has improved since the last inspection? The registered manager has now been at the home for about a year and during this time she has provided the staff with good leadership and given them a clear sense of direction. The manager has also identified and addressed shortfalls in the service provided and is proactive in making sure that people living at the home receive the care and support they need. Care plans and supporting documentation is now more person centred and gives clear guidance to staff on how people’s needs are to be met. What the care home could do better: Staff need to be more vigilant when managing medication so that people living at the home can be confident that their medication is being stored, administered, and disposed of appropriately. Although all care staff have one to one supervision meetings with the manager, they are not held as frequently as they should be. As supervision meetings support staff to plan their personal and professional development they should be held at least every two months. Some areas of the home including a number of bedrooms and corridors would benefit from refurbishing and old and tired furniture replacing. This will make sure that standards are maintained and people live in a pleasant and comfortable environment.The BorrinsDS0000001239.V378332.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE The Borrins Station Road Baildon Shipley West Yorkshire BD17 6NW Lead Inspector Steve Marsh Key Unannounced Inspection 5th November 2009 09:30 DS0000001239.V378332.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Borrins DS0000001239.V378332.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Borrins DS0000001239.V378332.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Borrins Address Station Road Baildon Shipley West Yorkshire BD17 6NW 01274 582604 01274 598066 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.bupa.co.uk BUPA Care Homes (GL) Ltd Louisa Hermann 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.V378332.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd October 2008 Brief Description of the Service: The Borrins is registered to provide personal care without nursing for up to thirty two people. The home is located near the centre of Baildon, a quiet suburb on the outskirts of Bradford. It is not far from the village centre and shops. The building is a period property, which has been adapted while keeping many of its characteristics. It stands in attractive grounds and car parking is available. The gardens are well maintained and easily accessible with walkways and plenty of seating. Bedroom accommodation is provided in single rooms, as all of the double rooms are currently only available for single occupancy. This means that the home’s maximum occupancy level is now twenty-five. The manager confirmed that the home is to contact the Commission in the near future with a view to reducing the number of registered beds to twenty-five on a permanent basis. There are two comfortable lounge areas with views of the gardens and a dining room. There is a passenger lift available to assist people with mobility problems reach the accommodation and facilities on the first floor of the building. Information about the home is kept in a file in the reception area as well as in people’s rooms. Information packs are posted to people on request. The current charges range from £397.79 to £693.00 per week. Items not covered by the fee include newspapers, hairdressing and chiropody. The home should be contacted directly for up to date information about charges. The Borrins DS0000001239.V378332.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star (2*). This means people that use the service experience good quality outcomes. The methods we used included looking at records, observing staff at work, talking to people living at the home and visitors, talking to staff and looking around the property. Before the visit we had provided some people living at the home, staff and other health care professionals with survey questionnaires so that they could share their views of the service with us. We received twelve questionnaires back from people living at the home some completed with the help of family members or staff, ten from staff and four health care professionals. The information they provided has been used as evidence in the body of the report. The home had also completed and returned their Annual Quality Assurance Assessment (AQAA) form and the information provided has also been used as evidence in the body of the report. The AQAA is a self assessment form that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. We have recently improved our practice when making requirements to improve national consistency. Some requirements from previous inspections may have been deleted or carried forward as recommendations, but only when it is considered that people that use the service are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Three recommendations have made as a result of this visit. Feedback was given to the manager at the end of the visit. What the service does well: The home is well managed and people are consulted about how they want their care and support to be provided. The manager has an open door policy and encourages people to tell her what they think about the service. There are regular meetings arranged for people living at the home and their relatives and there are recognised quality assurance monitoring systems in place. There is good and friendly interaction between the people who live at the home and staff and people are encouraged to make choices and decisions about how they want to spend their time while living there. The Borrins DS0000001239.V378332.R01.S.doc Version 5.2 Page 6 The home has established close working relationships with other health care professional to make sure peoples health care needs are met and they have access to the full range of NHS services. The chef is knowledgeable about peoples particular likes and dislikes and any special diets they need, and makes every effort to give people the foods they will enjoy. A thorough staff recruitment and selection procedure and a commitment to staff training makes sure that people that use the service are cared for and supported by staff that are suitable to work in the caring profession. Comments from people living at the home and/or their relatives included the following the home is well managed and the staff are kind and caring and “the food is good and plentiful and the rooms are clean and tidy.” What has improved since the last inspection? What they could do better: Staff need to be more vigilant when managing medication so that people living at the home can be confident that their medication is being stored, administered, and disposed of appropriately. Although all care staff have one to one supervision meetings with the manager, they are not held as frequently as they should be. As supervision meetings support staff to plan their personal and professional development they should be held at least every two months. Some areas of the home including a number of bedrooms and corridors would benefit from refurbishing and old and tired furniture replacing. This will make sure that standards are maintained and people live in a pleasant and comfortable environment. The Borrins DS0000001239.V378332.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 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.V378332.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, & 5 – Standard 6 is not applicable to this service. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admission process is thorough and people will not be admitted unless staff are able to meet their needs. People are provided with good information about the service and are encouraged to visit and see the facilities at first hand before deciding if the home is right for them. EVIDENCE: The information provided about the service is good and helps people decide if the home can meet their needs. At the current time the information is only available in English but the manager confirmed that it would be made available in different languages and formats on request. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 10 Records show that peoples needs are always assessed before they move into The Borrins either in their own home or temporary place of residence. Needs identified during this pre-admission assessment visit form the basis for the initial care plan, which is completed on admission. People are invited to visit the home before admission to see at first hand the facilities provided, meet the staff and other people living there and stay for a meal if they wish to do so. People are also able to move in to the home for a trial period if they are still undecided. This is good practice and shows that people are supported through the admission process. The home tries not to admit people on an emergency basis however if this is unavoidable a full assessment of their needs is completed on the day of admission. Feedback from people shows that they feel the information they received about the home before admission was very good and the initial visit was helpful and informative. One person told us that they had chosen the home because of its reputation locally for providing good quality care and facilities. They confirmed that they had not been disappointed with their choice and would have no hesitation in recommending the home to anyone considering respite or long– term care. Another person said that when they and their family visited the home they were impressed with the friendliness of the manager and staff who made them feel very welcome. Feedback from people also clearly shows that they feel there is a good mix of skills within the staff team and staff had a good understanding of their needs and preferences. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care and support is delivered in a manner that respects peoples privacy and dignity. EVIDENCE: Care plans are in place for all people living at the home and are initially generated from the information provided by the Social Services Care Management Team or the assessment of needs completed by the manager. Care plans are drawn up with the involvement of the person using the service and/or their relatives and form the basis for the care to be provided. The four care plans we looked at were completed to a good standard and were being reviewed at least monthly to make sure that they accurately reflected the level of care and support required by the individual. The information The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 12 provided was person centred and gave clear guidance to staff on how to meet peoples needs. Moving and handling and nutritional assessments are routinely carried out for all new admissions and risk assessments are also completed where areas of potential risk to peoples general health and welfare are identified, which is good practice. All people living at the home are registered with a general practitioner and are supported in having access to the full range of NHS services. The survey questionnaires returned by healthcare professionals show that they feel the home is meeting people’s health care needs and staff always seek advice if they have concerns. Comments included “the staff are generally helpful and friendly when I visit” and “staff always appear knowledgeable about people’s health care needs and from my observations always respect their dignity.” The home also operates the key worker system, whereby everyone living at the home has a named member of care staff as their key worker who is responsible for providing them with information and support throughout their stay. People confirmed that they were happy with the care and support they received and said that staff always treated them with kindness and respect. Comments included we are well cared for and the staff are kind and understanding and I am very happy with the care and support I receive. Feedback from relatives spoken with on the day of the visit shows that they are also pleased with the standard of care and facilities provided and were always kept informed of any significant changes in peoples general health. Throughout the day we saw that staff were kind and respectful. There was a lot of interaction with people and some good humoured banter which created a relaxed and warm atmosphere. We reviewed the medication system in place and found that generally medicines are managed safely. However, we did note that in some instances the Medication Administration Record (MAR) sheets were not being completed correctly by senior staff and the controlled drug register was not up to date. Staff must therefore be more vigilant when managing medication so that people living at the home can be confident that their medication is being stored, administered, and disposed of appropriately. Following the visit we received confirmation from the manager that all staff responsible for administering medication had received further training to make sure discrepancies in the system do not occur again. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are offered the opportunity to take part in a varied range of social and leisure activities that take account of their preferences and abilities. EVIDENCE: The manager confirmed that people are encouraged to make choices and decisions about how they spend their time whilst living at the home. Peoples personal interests are recorded in their care plan and wherever possible they are supported by staff to follow their own daily routines. The home has a designated activities co-ordinator who is responsible for organising in–house activities, entertainment and outings. For people that dont like to join in group activities time is made to engage with them on a one-to one basis. The majority of people told us that they were generally pleased with the level of activities and outings made available to them. One person in particular was very pleased to show us the painting she had recently completed and commented on how she enjoyed the range of activities on offer. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 14 However, the questionnaires returned by three people indicate that they would like the opportunity to take part in more social and leisure activities. Comments included “I would like to see more activities organised especially during the evenings” and “I would like to get out more – we sit around far too much.” The manager confirmed that people are encouraged to continue to attend their place of worship if they wished to do so and the home has established good relationships with local church groups. People spoken with said that they were able to see visitors in their own rooms if they wished to do so and family and friends were always made to feel welcome and offered light refreshments when they visited. We observed the lunchtime meal being served, which looked appetising and was well presented. Tables were nicely set, the meal was unhurried and the atmosphere was relaxed. If people required assistance or prompting to eat their meals this was done in a discreet and sensitive manner so that they were not caused any embarrassment. People told us that the food is always good both in quality and presentation and they are always offered an alternative if they dont like what is on the menu. Comments included you could not ask for better food – it is first class and I enjoy all my meals, the kitchen staff do an excellent job. During the course of the visit we had the opportunity to have a brief discussion with the chef who had a good understanding of people’s dietary needs and obviously took a great deal of pride in providing people with a varied and balanced diet. Following a kitchen inspection by the Environmental Health Department the home was awarded the maximum five star rating for food safety and hygiene. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable systems in place to make sure that complaints are dealt with appropriately and people are protected from abuse. EVIDENCE: There is a clear complaints procedure in place and information provided in the self assessment form shows that the home operates a zero tolerance approach when dealing with complaints and adult protection (safeguarding) issues. People living at the home said that they were aware of the complaints procedure and would have no problem at all in approaching the manager or registered provider if they had any concerns about the standard of care being provided. Information provided in the self assessment form shows that one complaint has been received since the last inspection and this was dealt with within agreed timescales. Adult protection policies and procedures are in place and training records provided by the manager show that all staff receive training in the recognition and reporting of allegations of abuse. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 16 Feedback from staff indicates that they are aware of the homes policy on whistle blowing and know what to do if they suspected that people were being abused or working practices at the home were not in the best interest of the people living there The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally maintained to a good standard, providing a warm and relaxed environment, however, some areas would benefit from refurbishing. EVIDENCE: All the communal areas including lounges and the dining room are on the ground floor of the home, conveniently close to toilet facilities. The standard of décor and furnishing in these rooms is generally good and they make pleasant areas for people to relax or take their meals. Bedrooms are situated on both the ground and first floor of the building and there is a passenger lift available to assist people with mobility problems reach the accommodation and facilities on the upper floor. On admission people are The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 18 encouraged to bring personal possessions into the home to personalise their room and it was evident during the tour of the building that many people had done so. The standard of décor and furnishing varied from satisfactory to good although a number of bedrooms and corridors would benefit from decorating and old tired furniture replacing. People living at the home said that they were generally satisfied with the standard of accommodation, and were pleased that they had been able to furnish their rooms with personal possessions. Feedback from relatives showed that they had mixed feeling about the standard of accommodation although the majority felt it was satisfactory. Comments varied from “some areas of the home are in need of decorating and generally brightening up” to “I am happy with the standard of accommodation and facilities provided.” The laundry is situated in a separate annex to the main building and on the day of the visit it was clean and well organised. It is apparent that laundry staff work to a high standard and take a great deal of care and personal pride in providing a quality service. Comments from people living at the home and/or their relatives included “the laundry service is very good my clothing looks like new when it’s returned” and “clean clothes, clean bedding what more could you ask of the laundry staff.” On the day of the visit the home was clean, tidy and free from offensive odours. Externally the grounds are pleasant and well maintained. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People that live at the home are protected by the staff recruitment and selection procedures in place. The home provides staff with good training opportunities and makes sure that they are clear about their roles and responsibilities. EVIDENCE: The home has a thorough staff recruitment and selection procedure, which includes obtaining at least two written references and a Criminal Record Bureau (CRB) check before new staff start work. This makes sure that people that use the service are cared for and supported by staff that are suitable to work in the caring profession. Survey questionnaires returned by staff show that they feel the recruitment procedure was thorough and carried out fairly. We looked at three staff recruitment files and found that they were kept in good order and contained all the relevant information. The staff rota showed that sufficient care staff are employed on day and night duty to meet peoples needs. Sufficient domestic and catering staff are also The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 20 employed to make sure the home is kept clean and people’s dietary needs are met. All new staff receive induction training in line with the Skills for Care Common Induction Standards. These are nationally agreed induction standards designed to help new staff get the skills and knowledge they need to care for people. Following induction there is an expectation that staff will study for a National Vocational Qualification (NVQ) at level two or three above depending on the post they hold. The home also provides staff with the opportunity to attend training courses on a variety of topics relevant to their roles and responsibilities and there is a training matrix in place so that any gaps in training can be easily identified. This shows that the home is committed to making sure that people are cared for by a skilled and experienced staff team. Feedback from the staff shows that they are happy with the level and standard of training provided and are encouraged to take up training opportunities. Comments included “my initial induction training was very good and I have attended several courses since taking up employment at the home” and “more emphasis has been put on training in the last year and this as improved the quality of the service we provide.” Surveys returned by staff also shows that the training they receive helps them understand the individual needs of people living at the home and keeps them up to date with new ways of working. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and the manager is quick to address matters raised by people living at the home and/or their relatives, or highlighted through the inspection process. EVIDENCE: Mrs Louisa Hermann is the registered manager of The Borrins Care Home. Mrs Hermann has many years experience in the caring profession and has achieved a recognised management qualification. Mrs Hermann has a positive attitude to the inspection process and during the course of the inspection showed a willingness to work with us to maintain and improve standards at the home. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 22 The manager continues to update her knowledge base and is aware of her duties and responsibility under the Mental Capacity Act deprivation of liberty safeguards. The manager is supported in her role by a deputy manager, an administrator and senior care assistants on day and night duty. Feedback from staff and people living at the home shows that the manager is very approachable and operates an open door policy, which means that they are able to speak to her at any time if they have concerns. Comments from staff included “it is very easy to approach the manager if you have a problem” and “the manager works within the home on a daily basis and is therefore available if you need to speak to her.” Comments from people living at the home or their relatives included “it is reassuring to know that I can speak to the manager or deputy manager at any time” and “the manager takes time out to speak with all the relatives visiting the home, which is thoughtful and shows she cares about the quality of the service provided.” The manager confirmed that care staff receive formal one-to-one supervision on a regular basis but acknowledge that she was finding it difficult to provide supervision in line with the National Minimum Standards and the guidelines set down by BUPA. She is however aware of the benefits of staff supervision and is currently looking at ways of improving the system including training senior staff on night duty to undertake supervision sessions for night care assistants. Supervision for auxiliary staff is already provided by the heads of department, for example the chef is responsible for providing supervision and support to the kitchen assistants. There is a range of quality assurance monitoring measures in place including sending out survey questionnaires to people using the service, their relatives and other healthcare professionals. The questionnaires give people the opportunity to express their views of the service provided and are an important part of the quality assurance monitoring process. As part of the quality assurance system the manager also arranges meetings for relatives on a regular basis and the home also publishes a newsletter, which keeps people up to date with events happening in the home, staff news and any changes which may affect people’s lifestyle. The home does not hold money in safekeeping for anyone living there but invoices people for any services provided, which are not included in the fees. Information provided in the self-assessment form completed by the manager shows that policies and procedures are in place to make sure staff follow safe working practices and all equipment is serviced in line with manufacturers guidelines. People can therefore be sure that their health and safety is not being compromised. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 23 The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 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 X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 2 X 3 The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Staff should be more vigilant when managing medication so that people living at the home can be confident that their medication is being stored, administered, and disposed of appropriately. Some areas of the home including a number of bedrooms and corridors would benefit from refurbishing and old and tired furniture replacing. This will make sure that standards are maintained and people live in a pleasant and comfortable environment. Although all care staff have one to one supervision meetings with the manager, they are not held as frequently as they should be. As supervision meetings support staff to plan their personal and professional development they should be held at least every two DS0000001239.V378332.R01.S.doc Version 5.3 Page 26 2. OP19 3. OP36 The Borrins months. The Borrins DS0000001239.V378332.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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