Inspection on 19/01/06 for The Old Hall

This inspection was carried out on 19th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Old Hall 23/08/07

The Old Hall 16/01/07

The Old Hall 27/06/05

The Old Hall 11/10/04

The Old Hall 02/08/04

The Old Hall 23/02/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Boughton Hall Boughton Hall Send Marsh Road Send Ripley Surrey GU23 7DJ Lead Inspector Mavis Clahar Unannounced Inspection 19th January 2006 09:50 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 Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 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. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Boughton Hall Address Boughton Hall Send Marsh Road Send Ripley Surrey GU23 7DJ 01483 211674 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) The Old Hall (Send) Co Ltd Charles Patrick Geoghegan Care Home 40 Category(ies) of Dementia - over 65 years of age (4), Learning registration, with number disability (1), Old age, not falling within any of places other category (40), Physical disability over 65 years of age (5) Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: over 65, one named person may be aged between 60 and 65 27th June 2005 Date of last inspection Brief Description of the Service: Boughton Hall (The Old Hall) is situated in a rural location a short distance from the village of Send. It is a large detached property set in its own substantial grounds. There are ample parking facilities at the front and the side of the building. Service users bedrooms are provided at ground and first floor level and all have en-suite facilities. The home has a wide variety of communal spaces including several lounges and dining areas. These are all situated on the ground floor; the standard of presentation, decoration and furnishings was very high. The home has a large patio area and extensive gardens at the back of the building. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. This inspection was unannounced, and was carried out on the 19th January 2006. No one at the home had prior knowledge of this inspection. The home received an Announced inspection on 27th June 2005. In order to have a full understanding of the way the home met the National Minimum Standards for Older People it is necessary to read both reports for the year March 2005 to April 2006. The first impression on entering the home was the strong smell of people smoking. This smell was overpowering and the inspector discussed the health implications for carers working in this environment where service users are given an open room as a smoking area. The first part of the inspection was spent explaining the process of the inspection to the head of care (the manager was away) as this was her first inspection. This was followed by a tour of the home except the smoking area because the inspector began to react to the smoke. During the tour, time was spent talking with many service users who all said they were very contented in their home. One service user said “I am as contented as one can be in a care home the staff are very kind and caring”. Another service user said, “ I have tried out many homes, but they did not meet my needs. I came here spent a week and have not gone home, this is now my home. I am fairly mobile and do go out on my own. I try to go for a walk every day weather permitting”. The inspector spoke at length with two visitors to the home. They were both very complimentary in their discussions about the home, its decorative condition, the care their relatives were receiving, they said the manager went to great effort to find a bed which was suitable for their relative. They also commented on the food, and although the inspector did not sample the lunch, it looked appetising, attractively served. Service users were observed eating their meal and when questioned they said the food was very good. The inspector noted that during the lunch period, lunch was served half an hour earlier to the less able service users so that carers could spend time offering any help they might require. Although a number of carers were in the dining room they were not intrusive on the service users they allowed service users space to eat their meal. This in the opinion of the inspector was highly commendable. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 6 Some requirements from the last inspection were issued again on this inspection, as the head of care had no access to paperwork to verify whether or not these requirements were carried out. Requirements arising from this inspection were also issued and these can be found in the table of requirements. Generally the home was clean and tidy on the day of inspection. Lastly the inspector would like to thank the head of care who very graciously accommodated her on this inspection. What the service does well: What has improved since the last inspection? What they could do better: Keep the COSH cupboard locked. In the house bathroom, hang the showerhead up on a permanent hook to reduce the risk of legionnaire disease. Have available a copy of the last report, service users’ guide and statement of purpose, for the use of service users. Address requirement relating to uneven floors in some upstairs bedrooms. Address requirement issued on the last inspection regarding consulting with the local environmental health officer regarding the erecting of fly screens to the windows in the kitchen. Risk assesses the open smoking area in accordance to health and safety at work for carers. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 7 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. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 8 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 Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 9 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): 136 Service users did not have all the information required to make an informed decision about choosing the home. The home was unable to demonstrate that all service users had a pre admission assessment carried out to ensure the home was capable to meet the care needs of the service users. The home demonstrated that standard 6 was met. EVIDENCE: Tour of the home, which included visits to service users’ bedrooms, and discussion with service users did not reveal any copies of the service users guide. During the inspection a copy of the service users’ guide could not be found. Random sample of service users files did not reveal any documentation that a pre admission assessment had taken place. The file of the most recent service user to be admitted into the home was reviewed and there was no documentation to show that preadmission assessment of needs was undertaken. The head of care was able to produce an uncompleted pre Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 10 admission form, but no completed form was available. A requirement was issued on this standard. There was no service user in the home under this category of care on the day of inspection. However, the home has demonstrated through discussion with carers, with service users that they are capable of providing for service users admitted under standard 6. A copy of the most recent report was not included with the service user’s guide available to each service user. A requirement was issued on this standard. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 11 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): 7 8 9 10 These standards were assessed on the last inspection EVIDENCE: For further information on these standards please refer to the inspection report of 27th June 2005. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 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): 12 13 14 15 These standards were assessed on the last inspection and remain unchanged. EVIDENCE: For further information on these standards please refer to the inspection report of 27th June 2005. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 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): 16 18 The home complaints policy and procedure is included in the service users’ guide to which each service user has a copy. Good attempt is being made through recruitment to protect the service users. EVIDENCE: Service users spoken to on the day of inspection were aware of how to make a complaint. However, service users informed the inspector that incidents are discussed with the manager or head of care as they arise so that complaints are never an issue. The head of care informed the inspector that no complaints were received by the home since the last inspection. There was no documented evidence i.e. complaint log available for the inspector to review to support this statement. The inspector was informed that there is a record of complaints but the manager was away and this record could not be found. The head of care informed the inspector that all care workers are POVA and CRB checked prior to been appointed. Two references are obtained and any gaps in employment history are investigated. This statement was not supported by documentary evidence as staff files are not available to the head of care, and the manager of the home was away on the day of inspection. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 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 26 Service users are not in a safe well-maintained environment. The home was clean and tidy on the day of inspection. EVIDENCE: Failure of the home to address environmental issues raised under The Care Homes Regulations 2001 in relation to standard 19 in the last inspection report has compromised the homes’ ability to meet standard 19, in that the home is not safe or well maintained. It was further noted that the COSHH cupboard was left open with a padlock dangling, and a support pillow was found stored on the floor of the linen cupboard. Immediate requirements were issued. In the House bathroom, it was observed that the showerhead was left hanging on the side of the bath. A requirement was issued to install a hook for the showerhead to prevent legionnaires disease. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 15 During the tour of the home it was observed that generally the home was clean and tidy and free from obnoxious odour excepting in the lounge nearest the open plan smoking area. The smell of stale smoke was so strong the inspector was chocking and could not inspect this area. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 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): 28 30 Staffing morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. EVIDENCE: Care workers were observed interacting positively with the service users, in a friendly but respectful manner. They were not intrusive, but were readily available to the service users. This is a very positive way of working, allowing the service users time and space, thus enabling, supporting and encouraging rather than taking away service users dignity. In discussion with care workers it was evident that training and development was given high priority. However, it came to light through discussion that care workers have not had training on POVA or Dementia. The designated trainer had already left the home and so documentation to refute or support this statement was not available. There was no record of training posted in the staff room or in the head of care office. In discussion it was evident the care workers had limited idea of POVA issues, but their knowledge on dementia care was very low. A requirement was issued on this standard. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 17 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): 35 The home does not become involved in service users finance. EVIDENCE: Service users are responsible for their finance, except for those service users who asks for their pocket money to be looked after for them. Records are kept of all transaction and receipts obtained. Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 18 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 2 X 1 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES 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. 2. 3. 4. Standard OP19 OP19 OP19 OP19 Regulation 13 13 13 13 23 Requirement To keep the COSHH cupboard locked at all times Remove the supported pillow from the floor of the linen cupboard Hang the showerhead in house bathroom on a hook to prevent legionnaires disease. Some of the floors in the upstairs bedrooms in the old house were observed to be uneven. It was a requirement that these be risk assessed in case they present a tripping hazard and appropriate action taken to minimise such risk. Time scale of 27/07/05 not met. The local environmental health officer should be consulted on the need for fly screens on opening windows and doors in the kitchen area. Timescale of 27/07/05 not met. Copy of the report must be included in service users guides situated in their bedrooms. Arrange for care workers to be trained as soon as possible in POVA and Dementia care. DS0000013570.V265230.R01.S.doc Timescale for action 19/01/06 19/01/06 10/02/06 27/02/06 5. OP19 23 27/02/06 6. 7 OP1 OP30 5 18 19/03/06 19/03/06 Boughton Hall Version 5.1 Page 20 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 OP26 Good Practice Recommendations Adopt the current smoking room so that it becomes a room with a door, which can be closed off, to reduce the strong smell of smoke in the lounge and dining area of the home. Fridge and freezer readings should be recorded twice daily preferable in the morning and last thing in the evening to reflect a true reading of the coldness of the fridge and freezer. 2 OP15 Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Boughton Hall DS0000013570.V265230.R01.S.doc Version 5.1 Page 22 - 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. 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