Inspection on 03/11/05 for Boucherne

This inspection was carried out on 3rd November 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

Boucherne 15/12/09

Boucherne 27/06/07

Boucherne 27/07/06

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 Boucherne Holloway Road Heybridge Maldon Essex CM9 4SQ Lead Inspector A Thompson Unannounced Inspection 3rd November 2005 11:00 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 Boucherne DS0000059320.V263062.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. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Boucherne Address Holloway Road Heybridge Maldon Essex CM9 4SQ 01621 855429 01621 854478 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) Boucherne Ltd Mr Christopher Tibballs Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Boucherne DS0000059320.V263062.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 24 persons) 2ND June 2005 Date of last inspection Brief Description of the Service: Boucherne provides residential care for 24 older people (over 65 years). The home is situated in Heybridge, a short distance away from Maldon town centre. The period detached property had been extended to provide additional accommodation but had not lost it’s character and homely atmosphere. The home had a good sized garden at the rear, with a smaller garden at the front. There was a car park for visitors to the side of the property. Accommodation was on two floors, accessible by stairs, passenger lift and stair lift. Accommodation comprised both single and double rooms. All rooms seen were well furnished and decorated. Local shops were a short distance away and the home was on a bus route. Boucherne DS0000059320.V263062.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 1100 hours on Thursday 3rd November 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/s 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: Provides a relaxed, comfortable and supportive living environment with good community contacts for residents. The management approach ensures good communication and liaison throughout the staff team on resident issues, and on the day to day service provision. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Staff recruitment records need to include copies of proof of identity. ---------------------- 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. Boucherne DS0000059320.V263062.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 Boucherne DS0000059320.V263062.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 of new residents. EVIDENCE: Prior to admission staff from the home visit prospective new residents to undertake an initial assessment of needs. The format used was seen and included headings of personal and background information, next of kin and GP, personal history, interests, medical needs, communication, cultural, sensory, mobility, personal care, continence, night care, diet, risks. Weight checks were included in weekly bathing records and oral care was included in the resulting care plan. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 9 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. EVIDENCE: Dental services are available to residents either by visiting local community based practices or by a dentist providing domiciliary visits to the home. Staff will initially assess for pressure sore risk and if needed will request formal assessment by district nursing services. Pressure relieving aids and equipment are provided by district nurses. Advice about the promotion of continence also comes from district nurses. Training on this subject is provided to staff at a local hospital. Certificates of attendance were available for inspection. The manager confirmed that residents are all weighted usually on a monthly basis, with their agreement. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 10 Nutritional advice and guidance is sought from a hospital based dietician. Two GP surgeries serve the home, one practice GP visits weekly (and on request). The other practice visit on request. Residents retain their own GPs where possible. Eyesight tests are accessed at an optician in Maldon. The optician also visits the home annually. A chiropodist visits every 8 weeks. The manager confirmed that he felt the home had good working relationships with both GP practices (regular advice is sought from the practice triage nurse), and with visiting district nurses. The home has a written policy and procedure for ordering, receipt, storage, and administration of medication to residents. There were also written guidelines for returning unused medication to the pharmacist. Several residents self administer their own medication. Lockable facilities were provided in their rooms for storage and a ‘medicines management’ assessment had been completed in each individual case (advised by manager). The manager confirmed that only trained staff administer medicines in the home, regular in-house supervision takes place to try to ensure best practice continues regarding medication issues. All new staff identified for taking responsibility for administering medication are assessed for competency by the management team before undertaking this role. Staff involved with medication also attend the ‘Safe Handling of Medicines’ training course at a further education college in Chelmsford. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 11 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: Personal items may be brought into the home on admission, records had been kept of these. Information on how to contact independent advocacy services was displayed in the home. Some residents retain control of their own finances, relatives support others. The main meal of the day is dinner (6pm), a choice is available. A hot or cold choice is also provided at lunch. Residents decide on their preferred choice each morning. Breakfasts are taken in the dining room or in residents own bedrooms. A cooked breakfast is available every day for those who wish. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 12 Supper snacks are available before bedtime. Menus are planned offering full involvement and discussion from residents. Comments received from residents were complimentary towards the food provided. Drinks are provided/available throughout the day and two staff are on hand in each dining room at mealtimes to offered assistance where needed. Several residents now meet in the ‘Panelled’ lounge every Sunday morning to take sherry. Staff only attend by invitation. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 13 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 home had a written policy on abuse & whistleblowing. This included clear guidance on types of abuse and the responsibility of staff to report any concerns to their line manager or relevant agencies. The most recent guidance and procedures issued by the essex vulnerable adults protection committee (EVAPC) were in place, as were the statutory local authority’s ‘adult protection guidelines’ and the Dept of Health’s POVA (protection of vulnerable adults) procedures. Reporting forms were also in place. The home’s induction foundation training package includes POVA and adult abuse issues, and National Vocational Award training (NVQ) includes sections on adult protection. Several staff have also attended the half day course provided by EVAPC on POVA procedures. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 14 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): 19,20,21,23,24,25,26 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: The home’s location and physical environment was considered suitable for it’s stated purpose. Residents’ bedrooms were in a good decorative order and maintained on a regular basis. The interior of the property is designed with residents’ needs taken into consideration. Access to wheelchair users was available throughout the gardens. Communal space in the home included three lounges, with one being designated as a quiet room, or a visitors area if residents required a private area with family or friends. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 15 Dining facilities include two rooms (one of which is adjacent to the kitchen), with seating for all residents. Furnishings in all communal rooms were of a good standard. The home had three communal bathrooms. Two of these provided assisted bathing facilities and one also had a seated shower facility. The third bathroom did not provide assisted bathing but was available for use. Sixteen single bedrooms and both shared rooms had en-suite wc’s. At the time of this inspection one of the shared rooms was continuing to be used as a single room. Communal wc’s were situated close to sitting rooms and dining rooms. Some first floor bedrooms had restrictors fitted to the windows some did not. The registered manager has advised that individual risk assessments had been completed on this issue. Some bedroom radiators were still unguarded. The registered manager had undertaken comprehensive risk assessments to confirm all reasonable steps had been taken to minimise risk to residents. However the inspector’s view remains that all radiators in the home should be guarded or have low temperature surfaces. There is a continuing recommendation on this issue in this report. Evidence was available to confirm that the home’s water storage tanks had been tested (in 2004) for safety (legionella), by appropriate contractors. Hot water in the home is regulated for supply at or close to 43 degrees celcuis, (not tested). All rooms were centrally heated. Heating could be controlled in individual rooms. The premises were free from any offensive odours. The laundry room was located in a timber outbuilding and was equipped with a washing machine with the appropriate temperature wash cycles and a sluice cycle programme. Latest available guidelines on infection control were available for staff to refer to. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 16 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, 29, 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. Recruitment procedures aimed at safeguarding the protection of residents had not always been followed. EVIDENCE: Staffing rotas were inspected. Morning shifts continue to comprise 1 x senior carer and 4 carers (including cooking duties for breakfast and lunch). Afternoon shifts comprise 1 x senior and 2 carers until 1830 hours, when an additional carer increases cover until 2000 hours. An additional carer also works 2130-2230 each evening and a cook works afternoons to prepare the evening meal (which is the main meal of the day). The care manager’s hours (Monday to Friday and one weekend in four) are additional to these numbers. Night staffing is 2 on waking duties, domestic staff is additional, Monday – Fridays. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 17 Staff recruitment records seen included an application form, references, copies of qualifications, CRB checks and terms & conditions of employment. Regulation requires that these records also include copies of proof of identity and a photograph. Not all files seen included these and there is a requirement regarding in this report on this issue. The home’s in-house induction format and process was unchanged since last inspected. It was been based on national training organisation guidelines. Included headings were: individuality, equal opportunities, communication, relations with residents, confidentiality, food hygiene, health & safety, eating & drinking, records, care plans, carers role, team work, service user role & perspectives, relatives, manual handling, personal care, medication, pressure care, needs of older people, confusion & dementia, infection control, first aid, death & dying. The induction package is worked through during the first six weeks of employment. All new staff are offered NVQ training on the next available course. Current numbers of staff with NVQ awards/training totalled: seven have the NVQ level 2 and two are undertaking this level, and six staff have the NVQ level 3 award with five undertaking this level. The care manager & the co-registered provider were NVQ assessors, the care manager was also a manual handling trainer. Individual staff training and development profiles had been maintained. The Care Manager confirmed training provided included: manual handling, fire safety, food hygiene, infection control, health & safety, medication, tissue viability, supervisory management, palliative care, bereavement & loss, Parkinson’s disease, dementia (at foundation, intermediate and a four day managers level course), continence promotion, working with older people, diabetes, and conflict management. The registered manager and the care manager have both completed the additional training modules necessary to achieve the full Registered Managers Award (the manager has previous management qualifications and the care manager is a qualified nurse). Three staff (the manager, care manager and a senior carer) had also recently undertaken a course entitled ‘Supervision in Care Homes. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 18 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): 33 & 37 Procedures for gaining the views of residents and relatives were in place. Not all records required by regulation were in place. EVIDENCE: The home’s quality assurance questionnaire form includes headings: health needs, food, staff attitude, accommodation, complaints. This is sent to residents and relatives (where appropriate) for completion. Records are kept of outcomes and of any resulting actions taken by the home. The care manager had just undertaken a review of actions resulting from the feedback and findings received in March. This exercise was to ensure that appropriate action had been taken in response to service user views. Residents’ views on food had also been sought through individual contact within the home and from viewing planned menus. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 19 Residents meetings take place, minutes of items discussed and decisions made are kept. Random samples of records required to be kept were inspected. These included: assessments, staff recruitment, staff rotas, accident records, visitors book, fire drills, regulation 37 notices, nutrition records, furniture brought in by residents, medication and fire procedures All seen were considered appropriately maintained except some recruitment records. See standard 29 for details. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 20 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 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 X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X 3 X Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 21 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 OP29 Regulation 17, 19, schedule 2 Requirement The registered manager must ensure that staff recruitment records include copies of proof of identity. Timescale for action 31/12/05 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 Refer to Standard OP25 Good Practice Recommendations The registered provider should ensure that all radiators in use in the home are guarded or have low temperature surfaces. Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 22 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 Boucherne DS0000059320.V263062.R01.S.doc Version 5.0 Page 23 - 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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