You are here

We are carrying out a review of quality at Borrage House. We will publish a report when our review is complete. Find out more about our inspection reports.
All reports

Inspection report

Date of Inspection: 16 May 2013
Date of Publication: 8 June 2013
Inspection Report published 08 June 2013 PDF

People should get safe and appropriate care that meets their needs and supports their rights (outcome 4)

Not met this standard

We checked that people who use this service

  • Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 16 May 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff.

Our judgement

People’s needs were assessed and care and treatment was planned and delivered in line with their individual care plan. However, people did not always experience care, treatment and support that met their needs and protected their rights.

Reasons for our judgement

When we arrived at the service all of the people using the service were in bed. We were told that the majority of people choose to get up after 8am. This was confirmed by the people we spoke with later the same morning.

At the time of our visit there were 36 people in residence. We checked the night records and we were concerned to find that the record did not accurately reflect the times care was being delivered. Staff told us they checked people during the night, according to the person’s wishes. Some people were being checked 'hourly' and others were checked 'at the start and end of the shift.' A 'check' was described by staff as 'popping your head around the door', assisting with personal care, repositioning people in bed or offering drinks. However, it was clear that the record was not being completed at the time the night staff were carrying out ‘checks’ or caring tasks and staff confirmed this to us. We saw that six people were recorded as being checked at the same moment, by the same member of staff. Some checks were recorded one minute apart. It was not possible therefore to know, the time people had received care, how long the care intervention had taken or indeed if any night checks had been made.

To check the validity of one record, we met a service user in their bedroom at 4.55am. This person was found in need of assistance to change their nightwear and bedding. The night log showed that this person had been checked at 3.11am. ('Hourly' checks were in place, so another check was due at around 4am.) It is of concern that none of the night staff could be sure when the person was last checked.

We observed the handover between the night and morning staff. This was detailed and included events which had occurred the previous day and night. This helped staff to deliver care that met people's health needs.

We looked at six care plans. We saw that an assessment had been completed before people had moved in. This meant that the service had sufficient information to be confident that they could meet a person's needs. The care plans were person centred and detailed support needs and contained information about the person's preferred daily routines and their past histories including important events and people in their lives.

Risk assessments had been completed which included areas such as mobility, manual handling, falls, skin integrity and nutrition. The risk assessments detailed the actions required to reduce any identified risk. This meant that staff had clear guidance on how to ensure the safety and wellbeing for each person. However, despite the nutritional tool being used effectively in some cases, we were concerned that in other examples we saw that appropriate action had not been taken.

In one instance a person had lost a significant amount of weight over four months, from July 2012 to November 2012, and staff had not seen this weight loss as a trigger for referring them to the doctor. Another cause for concern is that the person had not been weighed again since November 2012, therefore there was no indication of whether weight loss had continued. Another person had lost 8kg in one month, between August 2012 and September 2012. The weight loss was monitored for a further two months, showing another loss. Again there was no action taken to refer this person to the doctor. There were no further weights recorded, again indicating that monitoring had stopped.

Not all care plans had been reviewed recently. One had not been reviewed for ten months. Some care plans had been reviewed and recorded as 'no change.' Indicating that the care plan in place remained unchanged. However, in two examples, the person's condition had changed, for example they had lost weight. This meant that the information was not up-to-date and did not accurately reflect the person’s needs.

Some people needed their fluid and food intake monitoring and some people also had a ‘repositioning’ chart, which was used by staff to record when so