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CQC report explained · a residential care home

What the CQC found at Borovere

Goodpublished 4 July 2023, 3 years ago

Rated Good: inspectors found the home performing well and meeting their expectations.

The five questions inspectors ask
Safe?
Good
People were protected from abuse and avoidable harm. Inspectors found enough staff, safe medicines arrangements and suitable infection control, although some recruitment checks and water temperature checks needed attention.
Effective?
Good
This key question was not inspected in this report. Its rating was carried forward from the last inspection.
Caring?
Good
This key question was not inspected in this report. Its rating was carried forward from the last inspection.
Responsive?
Good
This key question was not inspected in this report. Its rating was carried forward from the last inspection.
Well-led?
Good
The manager and provider used audits, action plans and feedback to monitor and improve the home. Staff, residents and relatives were involved, although meetings for residents and relatives were not as regular as the manager wanted.
The latest report, explained

What inspectors found, July 2023

Borovere rated Good; inspectors found safe, well-managed care, with some recruitment checks needing completion.

The inspection was unannounced and took place on 26 April and 04 May 2023. One inspector and an Expert by Experience spoke with people, relatives, staff and the manager. They reviewed care records, medicines records, staff recruitment files and management records.

The home was rated Good for Safe and Well-led. Inspectors found enough staff, safe medicines processes, suitable infection control and systems to manage risks. People and relatives said they felt safe, and the home was clean and well maintained.

Some recruitment files were missing required information at the time of inspection. The manager acted immediately to put this right. Inspectors also noted that some water temperature checks still needed completing and that meetings for residents and relatives were not as regular as planned.

What inspectors praised
  • Enough staff

    Inspectors saw staff available when people needed support. Relatives also said staffing levels appeared sufficient.

    “There always seem to be enough staff about.” from the report
  • Safe medicines

    Medicines were administered and stored safely. Staff had training and their competence was checked.

    “Staff who administered medicines had appropriate training and their competency was checked.” from the report
  • Positive atmosphere

    Relatives described a friendly and comfortable home. Inspectors found that the manager worked with people and staff to support a person-centred culture.

    “It is a fun and jovial home. Everybody is comfortable, well-attended, clean, and happy. We would recommend it.” from the report
  • Quality checks

    The manager and provider carried out audits and used action plans to track improvements and risks.

    “There was a system of regular checks and audits to monitor the quality of service provided.” from the report
What inspectors were concerned about
  • Recruitment records

    needs fixing

    Some staff recruitment files did not contain all the required information when inspectors visited. The manager took immediate action to correct this.

    “Some recruitment files did not have all the required information at the time of inspection, but the registered manager took immediate action to rectify this.” from the report
  • Water safety checks

    needs fixing

    Some temperature checks linked to the water system had not yet been completed. The manager said these would be re-checked and followed up with maintenance.

    “Regular checks were done to ensure this was maintained, however some temperature checks needed to be completed.” from the report
  • Resident and relative meetings

    minor

    Meetings were not happening as regularly as the manager wanted. The manager planned to arrange more meetings.

    “Residents' and relatives' meetings were not as regular as the registered manager would like although those which took place were felt to be worthwhile.” from the report
Questions to ask them, based on this report
  1. 01Have all missing recruitment checks and documents now been completed for every member of staff?
  2. 02Have the outstanding water temperature checks and maintenance work been completed?
  3. 03How often are residents' and relatives' meetings now held?
  4. 04How are medicines checked if the electronic system is unavailable?
  5. 05What improvements have been made since the previous inspection in the areas not covered by this inspection?

This was a focused inspection of Safe and Well-led, including infection prevention and control; the other ratings used ratings from the previous inspection. This explanation was written from the published report of 4 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

An earlier report, explained

What inspectors found, February 2021

Borovere was inspected but not rated; inspectors found good infection control and compassionate support during the COVID-19 pandemic.

This was an announced, targeted inspection on 3 February 2021. It looked at how the home prevented and controlled infection during the COVID-19 pandemic.

Inspectors found good arrangements for visitors, protective equipment, testing, social distancing, admissions and cleaning. They were assured that the home had up-to-date infection control policies and could manage outbreaks.

People were supported to keep in touch with their families. Staff also supported people with compassion when pandemic restrictions caused distress.

The home was inspected but not rated. This was not a full inspection of all areas of care, so the report does not provide ratings for the other key questions.

What inspectors praised
  • Family contact

    People were supported to stay in touch with their families during the pandemic, including through phone and video calls.

    “People had been supported to keep in touch with their families throughout the COVID-19 pandemic.” from the report
  • Visitor safety

    The home had clear visitor procedures, including screening, temperature checks and protective equipment.

    “The expectations and procedures for visitors to the service were clear.” from the report
  • Infection control

    Inspectors found systems for PPE, testing, hygiene, social distancing and managing possible outbreaks.

    “We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
  • Compassionate support

    People were supported in a person-centred way when pandemic restrictions caused distress.

    “People were supported in a person-centred way, when implementing the changes and procedures required to minimise the risk of COVID 19 in the home.” from the report
What inspectors were concerned about

Inspectors raised no specific concerns in this report.

Questions to ask them, based on this report
  1. 01How are visitors currently screened and supported to visit people safely?
  2. 02How do you currently test staff and people living in the home for infections?
  3. 03How do you make sure staff have enough PPE and follow the latest infection control guidance?
  4. 04How do you support people who become distressed because of visiting restrictions or other changes?
  5. 05What are the current arrangements for helping residents keep in touch with their families?

This was a targeted inspection of infection prevention and control during the COVID-19 pandemic; it did not assess the other key questions. This explanation was written from the published report of 25 February 2021 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Borovere

4 rated inspections over 7 years: the service has improved, from Requires improvement to Good.

  1. July 2023Goodcurrent rating
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read what inspectors found at Borovere →

  2. February 2021Inspected but not rated
    Safe: Inspected but not rated

    Read what inspectors found at Borovere →

  3. February 2019Goodstayed Good
    Safe: Requires improvementWell-led: Good

    Read this report on cqc.org.uk

  4. February 2017Goodup from Requires improvement
    Safe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good

    Read this report on cqc.org.uk

  5. March 2016Requires improvement
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  6. August 2013

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  7. November 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  8. August 2012

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  9. November 2011

    Report published without a new overall rating.

    Read this report on cqc.org.uk

  10. December 2010

    Registered with the Care Quality Commission on 7 December 2010.

Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.

Next steps

Weigh the report against the rest

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