Inspection on 21/09/05 for Boarbank Hall Nursing Home

This inspection was carried out on 21st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Boarbank Hall Nursing Home 11/05/07

Boarbank Hall Nursing Home 21/12/05

Boarbank Hall Nursing Home 14/01/05

Boarbank Hall Nursing Home 07/07/04

Boarbank Hall Nursing Home 13/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Boarbank Hall Nursing Home Allithwaite Grange Over Sands Cumbria LA11 7NH Lead Inspector Marian Whittam Unannounced 21 September 2005 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 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. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Boarbank Hall Nursing Home Address Allithwaite Grange Over Sands Cumbria LA11 7NH 015395 32288 015395 35386 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Canonesses of Saint Augustine Sister Eileen Anne Pollard Care Home 27 Category(ies) of 27 OP - Old Age registration, with number 4 TI - Terminally Ill of places 4 PD - Physical Disability Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14 January 2005 Brief Description of the Service: Boarbank Hall Nursing Home is managed and run by the Augustinian Sisters and provides long term and respite care for up to 27 residents including terminal care and convalescent nursing care. Boarbank is located at the edge the village of Allithwaite, facing south and overlooking Humphrey Head and Morecambe Bay. The home is a short distance from the village of Allithwaite and its amenities, such as the public house, bus routes into Grange and the local post office/shop. Alongside the nursing home is the Sister’s own religious community, a guest house and a Chapel. Relatives and carers can stay in the community’s guesthouse and use their amenities. Accommodation in the home is on two floors and there are two passenger lifts. There are 25 single bedrooms and 1 twin room for a service user and a relative/ carer. The home has a fully equipped physiotherapy suite on site. The home has extensive gardens with a terraced area accessible to wheelchair users and a children’s play area in the grounds. The home also has its own kitchen gardens and grows some of its own vegetables for use in the home. There is car parking space at the rear and side of the home. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 21st September 2005 The early afternoon was spent talking with residents in their own bedrooms, speaking to the nursing staff and the senior nurse on duty and also looking at care plans. Policies and procedures and records were looked at in the morning. What the service does well: Residents spoken to liked the staff team and spoke well of them and said they felt that “staff listened”, were “first rate” and “were interested in them”. The home provided a comfortable, well furnished, maintained homely atmosphere for residents and visitors. Residents commented on how peaceful and calm the home was and that their care was never rushed. The home took care to maintain a high nurse/carer to resident ratio so that standards of care remained high. Residents and the local community were very involved in the life of the home with residents deciding on the activities and trips out. Residents were especially pleased with the standard of food provided and attention paid to meeting individual choice and preferences. Staff are aware of the needs of residents and worked well with relevant health care professionals to maintain an appropriate service for residents and prompt attention. Care plans are detailed and have an emphasis on the individual resident and their choices and preferences and were clear and up to date. The home promoted a supportive culture evident in the support given to staff in their work or when dealing with terminal care and those with family commitments. Staff said they felt they had the time and resources to give a high standard of care to the residents and so had a high level of job satisfaction. The staff on duty at the inspection responded positively to the inspection process and the management of the home responded quickly to any matters raised at inspections. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 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 standard(s) 3,4 and 5 A detailed assessment and care planning system and information from other agencies was in place to provide staff with the information they need to meet resident’s needs when they come in. EVIDENCE: Individual care plans showed that new residents needs had been assessed in detail before and following admission and their individual care plans developed from this. The home manager or senior staff did an individual assessment of needs to ensure that the home could meet them before residents came to live there. Where appropriate other care agencies and professionals including the local palliative care team were involved in providing information and making assessments of the needs to be met. A system was in place whereby assessments for respite residents were reviewed with regard to the current workload for staff and the level of existing resident dependency. This was good practice as it prevented the high nurse/ carer to resident ratio the home maintained being affected. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 9 Many residents came in for respite, sometimes for years and got to know the home that way. The home, although run by a community of Catholic Sisters, has residents from different faiths and care plans showed that different social, cultural and religious needs were assessed and planned for. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 10 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 standard(s) 7,8,10 and 11 Systems in place provide staff with the information they need to satisfactorily meet resident’s needs and promote and protect their personal dignity. The health needs of residents are being satisfactorily met with evidence of good multi disciplinary working to meet assessed needs. EVIDENCE: All residents have an individual plan of care that sets out their health, personal and social care needs and their care preferences. Any changes identified at evaluation had been incorporated into care plans and needs assessments and the plans were resident focused. One resident said, “ I don’t know of anything here you could improve, they really are such kind folk”. Another said “it is so peaceful here and no one ever rushes you, I have a bath every evening to help me sleep and I don’t need any tablets then”. There was evidence of prompt referral to health care and services and working well with other agencies and the actions taken following their involvement. Residents spoken with said their privacy was respected and felt their dignity upheld and their preferences followed. Observation during the inspection suggested that resident’s dignity was being maintained when receiving care and being assisted and independence and choice were being promoted. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 11 There were policies and procedures in place for care of the dying and staff had been given training from the palliative care team and care plans contained relevant information regarding terminal care and individual choices and attitudes. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 12 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 standard(s) 12,13,14 and 15 A programme of organised activities and outings is provided that takes into account resident’s preferences and capabilities. Choices about daily life and routines, contacts with family, friends and the local community are being promoted and maintained according to the residents recorded wishes. Dietary needs are well catered for with a balanced and varied selection of nutritious food that meets resident’s special dietary needs and individual choice. EVIDENCE: The home provides a range of group activities and entertainments, trips out 3 times a week in the home’s minibus and community social and religious events recorded in the social diary. Resident’s former hobbies and interests were recorded and individual abilities and capabilities were being given consideration in planning and carrying out the activities. One residents said there was plenty to do and was going to the two weekly musical evening that night. Other residents were getting ready for a trip out to a place they had chosen. Residents told the inspectors that they could chose to take part or not as they preferred. One resident said, “ There is plenty to do if you want to”. Residents said that they could come and go as they pleased, take their meals where they preferred and see who they wanted to. Several of those spoken Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 13 with thought the quality of the food provided was “excellent” and that “ you only have to ask for something and they get it for you”. All agreed there was a choice of food each day and that there was plenty of it. Some vegetables were grown in the gardens. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 14 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 standard(s) 16 and 18 The home has a satisfactory complaint system that both residents and staff were aware of. Residents felt confident that the manager would listen to them and act on any concerns effectively. There were adult protection procedures in place but these should be updated in line with multi agency good practice to make sure staff know what to do to protect residents. EVIDENCE: The home had a clear complaint procedure, displayed and made available throughout the home. There is a complaints logging system that records all complaints received and the details of the investigation its outcomes and the actions taken. The home has not received any complaints since the last inspection. Residents spoken with felt confident that any complaints or issues they raised would be dealt with quickly. One resident said they “could not imagine having anything to complain about, it’s marvellous here”. There were procedures in place to protect vulnerable adults and for whistle blowing but this needs updating to reflect current multi agency guidance so staff followed good practice. Training should be provided on this for staff. The home had procedures in place for dealing with verbal and physical aggression, restraint and appropriate codes of nursing practice. The home’s administrator kept all records of financial transactions securely. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 15 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 standard(s) 19, 20, 21, 22, 23, 24 and 26 The decoration and furnishing in the home was of a good standard. with evidence of regular maintenance and decoration. The home provided a clean, comfortable and homely environment for residents to live in and had the equipment they need to promote mobility and independence. EVIDENCE: The home is well maintained with regular, planned maintenance and a good standard of décor throughout that provides a clean, tidy and homely environment for residents. The lounge and dining areas were comfortable and well furnished with good lighting for residents. Outside the large gardens are attractive, well kept and have seating for residents. Residents said that they used the garden a lot in the summer months, and enjoyed them. There is a play area for visiting children that residents can see from their bedrooms. Resident’s bedrooms seen by the inspector had a high standard of décor, and furnishings, many with en suite toilets. The home has been increasing the number of en suite facilities for residents. Many residents had brought some of Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 16 their own possessions in and this made their bedrooms more personal and homely for them. One resident commented, “you couldn’t get better surroundings”. There is a range of equipment, nursing beds, two lifts and adaptations in the home to help residents make the most of their independence and to get about the home. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. The numbers of nursing and care staff on the rotas and on duty during the visit were at a high level to able to meet residents needs and had good recruitment practices to safeguard residents. Staff morale is high resulting in an enthusiastic, well trained team that works positively with residents to improve their whole quality of life. EVIDENCE: Staff rotas and observation during the visit suggested that the home had a stable staff group providing continuity for residents and high levels of nursing and care staff on duty to provide adequate nursing and personal care during the day and night. Staff spoken with enjoyed their work and morale was good. Staff spoke about the good opportunities for training on offer to them and the high level of support they received in their working lives. There are a high percentage of carers with NVQ level 2 qualifications and the home has an annual training plan. Recruitment procedures were good with all required checks undertaken for nursing, care staff and volunteers. It was recommended that all staff personnel files had a current photograph in place. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 18 Residents said that staff and management were “caring” and “friendly” and that “staff spend time with you”, one said “staff have a chat with you, not just about your care”. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 35 and 37 The manager and senior staff provide clear leadership and planning in the home and this is communicated to residents and staff. Systems for resident consultation and involvement are effective and quality monitoring systems and reviews are in place to promote residents interests. Procedures and practices are in place which safeguard resident’s financial interests. EVIDENCE: The registered manager, Sister Eileen Pollard, is a registered nurse, with post registration qualifications in the care of the dying and many years experience in nursing and care. Staff spoken with confirmed the home had regular staff meetings and provided good access to training and that it was a good working environment. Staff said that the manager and senior staff are approachable, helpful and family friendly in their working practices. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 20 Service users confirmed that they were involved in the life of the home, supported in maintaining their interests and recreational activities and that staff and management were always available and listened to what they had to say. The home kept records of all its financial transactions and these were kept by the Trustees and audited by The Charities Commission. The business and financial planning for the home was incorporated into the overall planning for the community. Records required by regulations were examined and were well kept and up to date and kept securely. Financial records were kept and maintained by the Bursar. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x 3 STAFFING Standard No Score 27 4 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 x x 3 x 3 x Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 22 NO Are there any outstanding requirements from the last inspection? 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 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. 2. 3. Refer to Standard OP18 OP18 OP29 Good Practice Recommendations The home should make sure its adult protection procedures are in line with current multi agency guidance. Staff should training on adult abuse and the protection of vulnerable adults. All staff should have a recent photograph on file. Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith, Cumbria CA11 9BP 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 Boarbank Hall Nursing Home F58 F10 s6136 boarbank v242371 210905 ui stage 4.doc Version 1.40 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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