Inspection on 01/12/05 for Boars Tye House

This inspection was carried out on 1st December 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

Boars Tye House 23/08/07

Boars Tye House 24/08/06

Boars Tye House 11/05/05

Boars Tye House 21/12/04

Boars Tye House 17/05/04

Boars Tye House 11/12/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Boars Tye House 20 Boars Tye Road Silver End Witham Essex CM8 3QA Lead Inspector A Thompson Unannounced Inspection 1st December 2005 10:30 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 Boars Tye House DS0000017775.V270068.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. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Boars Tye House Address 20 Boars Tye Road Silver End Witham Essex CM8 3QA 01376 584515 01376 585007 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) Mr Clive Weir Mrs Bernadette Weir Mr Clive Weir Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 27 persons) 11th May 2005 Date of last inspection Brief Description of the Service: Boars Tye House is a fully detached property originally constructed approximately three hundred years ago as a farmhouse. The property has been converted and extended into a twenty-seven place residential home for elderly people (over the age 65). Accommodation is in twenty-three single rooms and two shared rooms. Sixteen of these benefit from fitted en-suite facilities. Accommodation is provided on both floors of the home, with communal lounge/dining rooms on the ground floor. Access between floors is provided by a shaft passenger lift. Boars Tye House is located in the village environment of Silver End and is approached via a private drive alongside a large, landscaped front garden. At the rear of the home there is a small rear garden and patio area, which is fully enclosed. Ample car parking is provided to the front for visitors, and bus services pass the front of the building along the main road. Local shopping facilities are a short walk away. Externally the home is very well maintained retaining an attractive period appearance. Internally much of the character of the original property has been retained. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 1030 hours on Thursday 1st December 2005. This was the second inspection of this home in the inspection year 2005/6. The content of this report reflects the inspector’s findings on the day of the inspection, and from taking account of relevant findings from previous inspections of the home. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Some residents and staff were spoken with. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All residents spoken to expressed satisfaction with the care they received and with the quality of the food and accommodation offered. There were no relatives available to speak with, but questionnaires were left at the home so that they had the opportunity to make their views on the service known to the Commission. Staff confirmed they received good support from management. They also confirmed that they had been offered training appropriate to their role. What the service does well: The home’s management team works well as a supporting and cohesive unit, offering clear lines of communication and guidance to the staff team. Much of the private accommodation available retains the original character of the property. The whole premises, including the grounds, were very well maintained. A wide range of training opportunities are offered to staff. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Medication administration records must be correctly completed. ------------------- 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. Boars Tye House DS0000017775.V270068.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 Boars Tye House DS0000017775.V270068.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): 3 The home’s assessment format and process was adequate for ensuring that initial perceived needs were identified upon admission. Anyone considering moving into the home may visit to meet residents, staff and facilities, to enable them to assess the suitability of the service. EVIDENCE: One of the deputy managers visits prospective new residents to undertake an assessment of need. Headings covered included: personal care, health, diet, weight, sight, hearing, communication, oral, foot care, mobility, dexterity, falls, continence, medication, social, interests & hobbies, safety & risk and mental health needs. A care plan is compiled after admission. Residents and their families are invited to visit before admission, to meet with existing residents and staff. Initial admission of all new residents is on a fourweek trial basis, after which a review of placement is undertaken involving the resident, their relatives and the responsible social worker. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 9 Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 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 the following standard(s): 8&9 The health care needs of residents were generally assured. The home’s medication procedures, practices and staff training appeared to provide adequate guidance for dealing with medicines, however not all medication records had been correctly completed. EVIDENCE: District Nursing services support the home in pressure sore assessment and will also supply appropriate aids and treatment. A dentist visits the home to provide treatment (this was taking place on the day of this inspection), or residents may attend the dental surgery. Continence advice is provided by the community Continence Nurse who also visits the home. Specialist dietary advice is available/provided by the Dietician through referral from the GP. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 11 Hearing tests are available at a local hospital and eyesight tests (also taking place during the morning of this inspection visit), and chiropody services are provided to residents either by visiting practitioners, or by visiting community based facilities. A choice of two GP surgeries is available to residents, although most use the local practice in Silver End. One resident was continuing to administer her own medication. This medication along with all general medication held in the home is kept locked at all times when not actually being administered. The written policy and procedures relating to self administering residents was available for inspection, as was the written agreement between the resident and the home. Records and medication stocks for self medicating residents are checked weekly by staff. Evidence was available to confirm that staff receive certificated training in medication procedures on a course entitled “Safe Handling of Medicines”. The homes medication policy and procedure was unchanged. This covered areas of ordering, storage, administration, returns of unused stocks and also included was a written re-ordering procedure. A separate returns book/pad is maintained and was available for inspection. Medication administration records were inspected, not all had been fully completed. The deputy manager undertook to ensure that this issue was immediately addressed. There is a requirement in this report regarding this. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 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 the following standard(s): 14 & 15 Residents were supported in exercising choice regarding day to day routines in the home. Meals provided would appear to ensure a wholesome, varied and nutritious diet for residents. EVIDENCE: Staff support residents in maintaining control of their finances, personal allowance monies are held for safekeeping and records of transactions and receipts are kept. Advocacy support is available and has been provided in the past to one resident at the request of the home. Notices were displayed regarding access to this service. Records seen and inspection of private rooms confirmed that residents had been permitted to bring their own personal items with them on admission. Regular residents meetings take place, minutes had been kept of discussions and decisions, these were seen. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 13 Residents spoken with were satisfied with the food provided. Menus had been discussed at residents meetings. Some seasonal changes had been made to menus. Menus and nutrition records had been maintained. The main daily meal is lunch, with two choices. Residents decide their preference the afternoon before. The deputy manager confirmed that cooked breakfasts were available and that supper snacks of toast or sandwiches were also provided on request. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 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 the following standard(s): 18 Procedures and polices in place were aimed at protecting residents from abuse. EVIDENCE: The registered provider and one deputy manager are POVA trainers (approved by Essex County Council & Essex Vulnerable Adults Protection Committee). Certificates of qualification entitled ‘Training for Trainers in the Protection of Vulnerable Adults’ were seen. They have provided an in-house programme of training to staff on the subject of abuse and adult protection. Twelve training certificates were seen, these were headed ‘Awareness in the Protection of Vulnerable Adults’. The homes own in-house policy on adult protection was inspected, this included guidance for staff on recognising and reporting abuse and action to be taken by staff and the person in charge if abuse is suspected. The home had a copy of the latest POVA guidelines and associated reporting forms. NVQ training also includes adult protection issues. The home also had a ‘whistle blowing’ policy which provided guidance to staff on their responsibilities to report any concerns to management. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 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 the following standard(s): 19,20,21,22,23,24,25,26 Furnishings in the home looked comfortable and the premises were well maintained. The premises appeared generally safe, accessible and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was considered clean and hygienic. EVIDENCE: Boars Tye House is a converted farmhouse set in the village of Silver End, nearest towns are Witham and Braintree. The home is accessed via a private drive alongside the home’s large landscaped well maintained front garden, which is fully accessible to residents. There is also a smaller enclosed rear garden accessible from the conservatory and the back of the home. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 16 The home was fully accessible to residents’ currently accommodated and was very well maintained externally and internally. Individual private accommodation and facilities are all considered to be of a good standard with renewal of equipment and maintenance undertaken on an as and when required basis. Bedrooms are usually re-decorated when empty. The registered provider/manager had advised that since the last inspection bedrooms 8,17 & 20 have been decorated. Local shops are a short walk from the home and a bus service passes along the main road to the front of the property. There is one designated dining room in the home with one lounge/dining room and a further lounge and conservatory area, all on the ground floor. A small quiet area on the first floor has been set aside as a visitors area, should residents wish to meet their visitors away from the main lounge. Lighting in communal rooms was considered domestic in character and sufficiently bright. The furnishings of communal rooms were mainly domestic in character, of good quality and appropriate to the range of needs of residents. There are three communal bathrooms, two provided assisted bathing and one did not. All three bathrooms in the home have WC’s and in addition there are four separate communal WC’s (three on the ground floor and one on the first floor). Sixteen private bedrooms in the home benefit from fitted en-suite WC. A designated hair dressing room has been provided (this was previously an unused bathroom). Staff call systems were located in all private rooms and communal rooms seen. The home is equipped with a shaft passenger lift to provide access between floors. There were three portable hoists available for use by staff when resident’s require this level of support. Grab rails are located in corridor areas of assessed need. Ramps were seen to be fitted to appropriate areas to facilitate wheelchair access internally and externally. Adaptations, aids and equipment in the home were considered by the inspector to be suitable and appropriate for the residents’ currently accommodated. The Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 17 two deputy managers have recently completed a training course on environmental occupational therapy assessment. Rooms were well decorated, comfortable and evidenced individual taste. Preferences are encouraged/respected. Door locks and keys are provided according to individual choice and risk assessment. Residents’ spoken with confirmed that they were satisfied with their rooms and with the facilities and choices provided to them. All rooms inspected were naturally ventilated with windows and all were centrally heated. Hot water supplying the home is regularly tested by staff and records were available to confirm that baths are checked to ensure that temperature is 43 degrees celcuis before residents get into the water. However regulator valves were not been fitted to hot water supply to mechanically restrict hot water supply at or near to 43 degrees celcuis. There is a recommendation regarding this item in this report. It is understood by the inspector that the local authority environmental health department has confirmed acceptance of the current arrangements and risk assessment in the home relating to hot water supply. All radiators in the home, seen, were guarded and lighting in residents’ rooms was considered domestic in character and fully appropriate for individuals requirements/needs. On the day of the inspection the premises were considered to be very clean and hygienic. Policies and procedures were available for inspection confirming that working practices are in place to control the spread of infection. A separate sluice is provided. The home’s laundry room was inspected and was equipped with appropriate industrial type washing machines and tumble driers. Washing machines were seen to be equipped with minimum 65 and 90°C wash cycles. The laundry flooring had an impermeable finish. Walls and work surfaces met the standard. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 18 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): 27,28,30 Staffing levels and skills appeared to meet the needs of residents. Staff were provided good training opportunities to equip them with the skills for their role. EVIDENCE: The home’s staffing rota was inspected and confirmed that staffing levels are being maintained at five care staff on duty on daytime shifts (including the person-in-charge). Night time staffing is three on waking duties. Separate and additional rostered staff were employed to undertake cooking, kitchen assistant, administrative, activities, domestic and maintenance duties. Additional domestic staff had been employed since 2004, this resulted in improved cleaning schedules in the home. The registered provider/manager has completed the Registered Managers Award (NVQ level 4). One deputy manager has commenced the NVQ level 4 and one staff member was studying to be an NVQ Assessor. Four staff were undertaking the NVQ level 3, seven staff had this award. Five staff were undertaking the NVQ level 2, four staff have this award. Two staff have the GNVQ Health & Social Care award. This equates to over 70 of the staff team with or studying towards NVQ qualifications. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 19 New staff undergo the home’s own induction programme. This includes headings of: principles of care, personal care provision, routines, effects of the setting on service users, maintaining safety at work and code of conduct. One deputy manager is a Manual Handling Trainer and a POVA (protection of vulnerable adults) trainer, and is therefore qualified to train staff in-house on these subjects. Staff training records had been maintained and evidenced that wide ranging training opportunities have been provided to staff in: fire safety, first aid, health & safety, infection control, food hygiene, medication practices, moving & handling, bereavement, sensory awareness, managing aggression, risk management, tissue viability, introduction to dementia, bowel & catheter care, POVA, preventing falls and fractures in care, funerals, personal safety awareness, pressure care & continence promotion and environmental OT assessment Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 20 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): 31,33,35,36,37 The home is run and managed efficiently and effectively. Procedures for gaining the views of residents, relatives and visiting professionals were in place. Not all records required by regulation were up to date. Residents financial interests were supported and appear to have been safeguarded. EVIDENCE: The registered provider is now also the registered manager. He has completed the registered managers award and has undertaken other training relevant to the service provision. His experience fully meets the requirements for the manager’s role. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 21 A quality assurance survey had been undertaken in July 2005. Questionnaires had been sent to and completed by: residents, relatives, district nurse, GP, social workers, dentist, opticians and chiropodists. Thirty eight responses had been returned and these had been collated and reviewed by the home, with an action plan summary completed for any resulting actions taken. The quality assurance process includes asking for the views on the service, including staff attitudes & care provided, food, accommodation, activities and the information provided by the home. Some residents personal allowance monies were held for safe keeping by the home. Records of transactions, receipts and balances held were kept. A random sample of these checked were satisfactory. Recent staff supervision appeared to have been undertaken on an informal basis, with a written record seen of the issues discussed with details and any actions required and a target. These recordings were infrequent (two since June 2004). Staff appraisal meetings take place every 12 months. These are undertaken by the provider/manager. Records of these included overall performance, problem areas, priorities, development needs and conclusion with recommendations for action resulting. Standard 36 states that care staff receive formal supervision at least six times a year. The combined meetings that had been recorded over the past 12 months did not meet this, and there is a recommendation in this report that care staff are provided the opportunity for 1-1 formal recorded supervision /support meetings six times a year. Random samples of records required to be kept were inspected. These included: assessments, staff rotas, accident records, visitors book, fire drills, regulation 37 notices, nutrition records, menus, furniture brought in by residents, medication, background info’ and next of kin details, cash held for safekeeping and fire procedures All seen were considered appropriately maintained except some medication records. See standard 9 for details. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 X Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 23 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. 1 Standard OP9 Regulation 17, schedule 3 Requirement The registered provider/manager must ensure that medication administration records are kept fully up to date. Timescale for action 02/12/05 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 Refer to Standard OP25 OP36 Good Practice Recommendations The registered provider/manager should ensure that hot water supply in the home is regulated to ensure delivery at or close to 43 degrees celcius. The registered provider/manager should ensure that care staff are offered 1-1 formal recorded supervision meetings at least six times a year. Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Boars Tye House DS0000017775.V270068.R01.S.doc Version 5.0 Page 25 - 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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