Inspection on 21/08/08 for Boroughbridge Manor & Lodge

This inspection was carried out on 21st August 2008.

CSCI found this care home to be providing an Poor service.

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

Boroughbridge Manor & Lodge 02/02/10

Boroughbridge Manor & Lodge 20/08/09

Boroughbridge Manor & Lodge 16/12/08

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOMES FOR OLDER PEOPLE Boroughbridge Manor & Lodge Roecliffe Lane Boroughbridge York YO51 9LW Lead Inspector Bridgit Stockton Key Unannounced Inspection 10:00 21st August 2008 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 Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boroughbridge Manor & Lodge Address Roecliffe Lane Boroughbridge York YO51 9LW 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) 0845 603 8218 01423 326 377 boroughbridgelodge@orchardcarehomes.com www.orchardcarehomes.com Orchard Care Homes.Com Limited Manager post vacant Care Home 76 Category(ies) of Dementia (42), Old age, not falling within any registration, with number other category (34) of places Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC; to service users of the following gender: Either; whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP; Dementia - Code DE. The maximum number of service users who can be accommodated is: 76 New service 2. Date of last inspection Brief Description of the Service: Boroughbridge Lodge And Manor care home can accommodate up to 76 older people, who require help with personal care including some people with mental health needs. The home is a new building situated in its own private grounds, only a short distance from the market town of Boroughbridge. All of the bedrooms are well equipped and have en-suite facilities including an assisted shower. All floors are serviced by a shaft lift. Boroughbridge Manor & Lodge DS0000070786.V367827.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 0 star. This means the people who use this service experience poor quality outcomes. The methods I used to gather information included a visit to the home, conversations with the people who live there, their relatives, healthcare professionals and the staff. I looked in detail at the care and records of four people, examined other records and looked around the home. On this visit I was also accompanied by two members of staff from North Yorkshire County Council (NYCC). Over previous months the home has been working very closely with both NYCC and the Commission to resolve some concerns and issues that had been raised about the standards of care within the home. A random inspection had also taken place the previous month at the home and we also looked at what progress had been made in meeting some of the requirements made from that visit. What the service does well: What has improved since the last inspection? This is the first key inspection of this service. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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 Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. People’s needs are assessed prior to admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans I looked at showed that pre-admission assessments had been carried out before offering someone a place. A senior member of staff visits the person at home or in hospital to discuss their care needs. This is to make sure the home has sufficient resources and skilled trained care staff to provide the appropriate care. I spoke with some relatives who were visiting the home and they confirmed that their relative had been visited by a member of staff from the home and that they were given good information about the home and it’s facilities. They had also taken the opportunity to come and visit the home with their relative to see if it was suitable. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 9 Intermediate care is not provided at this home and therefore this standard was not assessed. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is poor Care plans do not provide staff with enough detail to meet peoples identified health and personal care needs. This coupled with poor practice in the administration of medication puts some people at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: I looked at four care plans in detail, to make sure that people’s health and personal care needs are being met in the way the person prefers to help them maintain their health and well-being. The four care plans looked at are not written in enough detail to ensure that people’s needs could be met. In most of the plans the daily evaluation/progress sheets was kept up to date and reported any changes to the persons care needs, however the actual plan of care was not altered to reflect these changes. For example it was noted that in one plan a person had developed a sore on their leg. This was recorded in the daily evaluation, and staff were asked to ‘monitor this’. Nothing had been altered in the plan of care for looking after a wound and there was no further Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 11 documentation about this. Other examples were discussed with the managers during the inspection. During my visit I looked at how people’s medication was looked after by the staff at the home. Some staff were not following the medication policy and procedures of the home. Some tablets were difficult to audit because there was not a record of what medication the home had received or what the existing stock balance was. Some staff had not signed the medication administration record to denote that medication had been administered, and some tablets could not be accounted for. We also observed one member of staff secondary dispensing medication. This is very worrying as staff had as a result of adult protection incident, and a requirement made at the random inspection just received medication training. To reduce the risk of harm to people, I asked the manager to obtain further training for all staff who administer medication. She needs to make sure that staff are properly trained, aware of the medication policy and procedures in the home and are safe to handle people’s medication. We have also requested that the pharmacist from the local Primary Care Trust visits the home to offer guidance and support to staff who administer people’s medication. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14&15 Quality in this outcome area is good. The recreational and social needs of people are well catered for which enables them to make daily choices and promotes independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People told me they had a choice of what they did during the day, one person told me they ‘went for a snooze’, after lunch. Another person said ‘I like to walk into town each day for a newspaper’. During this visit some people were sat in small groups in the dining area playing dominos. There is an activities program published each week and given out to each resident, however some of these sheets were out of date and remained in circulation in the dementia unit. There are also notice boards in the home to provide information and prompts to residents. All boards recorded different days of the week, a different daily menu, and different activities, this is really confusing given that some people who access this service suffer dementia. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 13 Everyone said the food was good, and a choice of meals was offered. People could either have their meals in the communal dining area or else in the privacy of their bedrooms. The majority of people chose the communal facilities. The menus were well thought out. I spoke to the cook; she was knowledgeable about people’s diet requirements and knew what people liked to eat and what portion sizes they preferred. If anyone needed extra supplements during the day, milkshakes, ice-cream and fruit smoothies were some of the things offered. One person said ‘I eat very well, we get a nice choice, I have no complaints about the food’. On each unit there was available fresh fruit, crisps, biscuits and snacks for people to help themselves. One person said ‘the food is great, we get what we want. I have just made myself a coffee and brought a banana back to my room for later. This really suits me; there is always something to snack on if we are peckish’. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 Quality in this outcome area is poor People’s concerns and complaints are not always dealt with properly. People are at risk from lack of action taken by senior staff when a potential abusive situation takes place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both the Commission and North Yorkshire County Council had been contacted by several ex-members of staff raising some concerns about the care practices at the home. The area manager for the home had also been made aware of these concerns from staff by letter, but had failed to respond to the concerns promptly. It is important that if people make a complaint or raise concerns using the whistle blowing procedures, they are recorded properly and responded to appropriately by letter, so there is a record of how the complaint has been dealt with. The record should also detail what action if any the home has taken. This is part of the company’s policy and procedure on ‘whistle blowing’. There was also an issue around the reporting of safe guarding matters promptly to the local authority who are the lead agency when dealing with vulnerable adults who may be at risk of harm. We asked the home to provide training in the safeguarding of adults procedures. All staff have now received training in this, including senior Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 15 managers within the company so they are now aware of the correct procedure to follow should an incident be reported to them. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19&26 Quality in this outcome area is adequate Whilst the home was decorated and furnished to a very good standard, bedrooms and some communal areas were dirty. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This is a new home, the furniture is good quality and the home is well decorated. There was equipment and aids available for people such as assisted bathing facilities, specialist beds and pressure relieving mattresses and cushions and electric hoists. Each unit has communal dining and lounge areas with kitchen facilities, a quiet lounge area and assisted bathrooms. All of the bedrooms are en-suite with an assisted shower facility. We looked at some peoples bedrooms. We found that some had not been cleaned properly, they had not been vacuumed and some of the en-suite facilities were smelly and dirty. Some of the flooring in the en suite looked heavily stained with urine. In one unit a lounge chair was stained with faeces, the carpet was dirty and the coffee tables were stained where drinks had been Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 17 spilt and not cleaned up. Some sluice doors were not locked and chemicals were stored here, potentially posing a risk to the people who were looked after on this unit. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. People are not employed or deployed properly in sufficient numbers to meet the needs of the people who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the hours staff worked on a weekly basis. The duration for the majority of care shifts was for twelve hours. Several staff regularly worked over sixty hours per week. Staff told us they were tired and often worked short staffed. We were told that often a senior member of staff would start duty at 07:00hrs and give out medication they would then work a twelve hour shift and if there was no senior care assistant cover for the night shift would stay until 22:00hrs to administer night time medication. It is my view that this is not a safe practice. On the morning of the visit the home was short staffed the atmosphere was chaotic. Three people told us they had waited for over an hour for a drink, they also said that service at breakfast had been very slow and they had been left sat at the table for a long time until staff managed to ‘get to them’ I looked at a selection of staff files. They all included completed application forms and two written references. The files showed that satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 19 checks have been obtained. I was assured that no new member of staff starts work until a POVA register check had been completed. Then, if the CRB check had not been received, they would work only under the supervision of an experienced staff member. All staff are given an induction pack which contain policy and procedures and are based around the skills for care training program. Supervision of staff had taken place but the frequency needs to be increased. A company trainer has been appointed to the home and training is taking place in moving and handling, health and safety, protection of vulnerable people and infection control. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 &38 Quality in this outcome area is adequate. Management of the home needs to be improved so that people’s health and welfare is safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management arrangements at the home need to be improved in order that people can be cared for properly. Time, resources and support need to be given to the acting manager in order for her to rectify the issues that have been raised within this report. Residents, relatives and staff meetings are held, and there were minutes available. The home sends out questionnaires to relatives, in order to gain information about how people view the service and what improvements they Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 21 would like to see. The operational manager visits the home and carries out audits, to make sure the home is operating to company policy. People who live at the home said that they are often spoken to by a senior manager in the company to ask how they are finding living at the home and to offer suggestions on how things could be improved. I looked at the records held at the home regarding people’s personal allowance. All transactions are recorded and receipts are kept. One person’s money was counted and matched the total on the record. All the regular health and safety checks for the home are carried out in a timely manner. Staff have had basic health and safety training which is covered at induction. Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 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 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 x x 3 Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/a 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 OP7 Regulation 15 Requirement Care plans must be written in sufficient detail to instruct staff on the care people require in order that there identified needs can be met properly. For the health and protection of people who live the home, all medication that is administered by staff must be recorded accurately. All staff that deal with people’s medication, must have further training in the homes policies and procedures that surround medication systems. Secondary dispensing of medication by staff must cease, in order to reduce the risk of medication errors. Complaints and concerns must be dealt with properly and in line with the homes policy and procedures on dealing with complaints. The home needs to be cleaned properly. Flooring, furniture, bedding and rooms that were identified during the inspection need to be either cleaned DS0000070786.V367827.R01.S.doc Timescale for action 31/10/08 2 OP9 13,17 Schedule 3 31/10/08 3 OP9 13 21/08/08 4 OP16 22 21/08/08 5 OP26 13 &16 31/10/08 Boroughbridge Manor & Lodge Version 5.2 Page 24 6 OP27 18 7 OP31 9 properly or replaced. Cleaning schedules need to be introduced and the manager must monitor these in order to maintain a clean, comfortable home. In order to meet peoples identified needs more skilled staff need to be on duty at busy periods during the day. In order that the care home is managed properly a suitable person needs to make application to the Commission for Social Care Inspection to become the registered manager. 31/10/08 31/12/08 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 OP8 Good Practice Recommendations It is recommended that people are referred promptly to other health care professionals should an identified issue or problem arise when caring for someone that cannot be dealt with by the staff working at the home. A review of how many hours staff are working in one week needs to be carried out. In order that staff are not working excessive hours covering shifts. 2 OP27 Boroughbridge Manor & Lodge DS0000070786.V367827.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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