Inspection on 23/08/07 for The Old Hall

This inspection was carried out on 23rd August 2007.

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

The Old Hall 16/01/07

The Old Hall 19/01/06

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 Lesley Garrett Unannounced Inspection 23rd August 2007 09:00 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 Boughton Hall DS0000013570.V345998.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. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 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) pierrej@therectory.co.uk 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.V345998.R01.S.doc Version 5.2 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 16th January 2007 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 home has a large patio area and extensive gardens at the back of the building. The fees charged in this service range from £570 to £685 per week. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced ‘Key Inspection’. Mrs L Garrett, Regulation Inspector, carried out the inspection and the manager represented the service. The inspector arrived at the service at 0900 and was in the home for five hours. It was a thorough look at how well the home is doing. It took into account detailed information provided by the home and any information that CSCI has received about the service since the last inspection. The inspector spent time talking with people living at the home in order to seek their views about the home and the care they receive. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the home’s Statement of Purpose and Service User Guide, care plans, daily records and risk assessments, medication procedures, staff files, a variety of training records, and the home’s safeguarding and complaints policies and procedures. The home had also submitted the Annual Quality Assurance Assessment (AQAA) prior to the inspection. From the evidence seen and comments received, we consider that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. What the service does well: Pre-admission assessments are all carried out prior to any individual moving into the home. The home has a good range of activities on offer and a programme of events clearly displayed. Visits are arranged to the seaside and places of local interest and in the month of the site visit there were animals visiting the home. The standard of food served in the home was of a high quality and we were told during the visit how much both people who use the service and visitors enjoyed this. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 6 The home has a good level of staff on duty with support from a housekeeping team, maintenance, chefs and kitchen staff. Staff are also supported to attend a variety of training which includes the National Vocational Qualification. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Boughton Hall DS0000013570.V345998.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 Boughton Hall DS0000013570.V345998.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): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have a pre-admission assessment and are confident that their needs will be met. The home does not provide intermediate care beds. EVIDENCE: The manager told us that they are in the process of rewriting their service user guide. The current guide is available for all prospective visitors to the home. It is a requirement at the end of this report that the new guide is sent to CSCI for our records. All people who use the service have a pre-admission assessment so they can be assured that their needs can be met. The manager stated that he, the deputy or the two deputy heads of care do the visits. The manager said that most people visit the home themselves prior to admission and they can also Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 9 stay for lunch if they wish. The manager said that care plans are then drawn up from these assessments. Boughton Hall DS0000013570.V345998.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 good. This judgement has been made using available evidence including a visit to this service. People who use the service have individual plans, which reflect the care and support they require and that their health care needs are fully met. The medication policies and procedures that are in place and implemented by staff protect service users. The privacy and dignity of the the individuals is respected. EVIDENCE: We sampled three individual plans of care and the manager stated that they are kept in the individual’s bedrooms and all personal details, for example next of kin and who to contact in an emergency, are kept in the office. Staff have access to this information at all times. A discussion took place with the manager about the quality of these plans and he stated that they were in the process of being expanded to capture more information. A computer system has recently been purchased and the home will be using this system. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 11 We spoke with some people who use the service and one person stated ‘we are very well looked after here’ and ‘mum has gone from strength to strength since being here’. A local General Practitioner (GP) who visits every Wednesday supports the home and the manager stated that she is a good support to them and they have access to her whenever they need it for advice or extra visits. They are also supported by an in-house physiotherapist who visits every week, a chiropodist and opticians. The district nurse is also a frequent visitor and will often visit with the GP. The manger stated this allows good communication between the home, people who use the service and health care professionals. We observed the medication policy of the home and the deputy stated that all staff follow this policy and have training before they administer the medicines. All medicines that are not administered have reasons stated on the back of the medicine administration record (MAR). The deputy told us that the GP reviews all of the medicines at least every year and more often if required. During the last site visit in January 2007 a recommendation was made for the home to include a photograph of the people who use the service to put in the MAR folder to clearly identify each individua, and the manager stated that this is in the process of being completed. The home has a privacy and dignity policy and this is also discussed during staff induction. Individuals can see visitors in private and on the day of the site visit one person had reserved a room to enable them to meet with their financial advisor in private. All people who use the service are addressed by their title, Mr or Mrs, unless otherwise stated in their care plans. One survey form returned to us said ‘they make my mother feel special and treat her with dignity’. Boughton Hall DS0000013570.V345998.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 excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to exercise choice and control in all that they do and the food is of a good quality. EVIDENCE: The manager told us that the home has two activity organisers and there is also a co-ordinator who works between the two homes in the group. All training for these organisers takes place at the other home but a record of their training is kept at the home where they work. The home has a published programme of activities, which we observed and noticed that the activities are spread throughout the day. The programme on display was for the current month of August, and this included a visit to a local pub for pre-lunch drinks, an exercise class, an outing to Clandon Park and another trip to Worthing. The manager stated that two of the local churches hold services at the home the Church of England and Roman Catholic. He stated that any denomination can be catered for and has been in the past. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 13 The manager stated that the home will have the benefit of a volunteer who will be visiting soon to spend time with individuals who may have no visitors or who would like a chat and to have coffee with them. Local schools have visited the home on special occasions, for example at Christmas to sing to the individuals. The home has a full time and part time chef and between them they provide all the food in the home, which is all homemade. Comments received from the people who live at the home and on returned surveys were complimentary about the standard of food provided. One individual stated ‘the food is very good’ and a relative said ‘I often stay to lunch, the food is wonderful’. The home had organised a barbeque the previous week and one individual told us ‘we have a very good chef, always plenty of food. We had a barbeque the other night but I didn’t like that food really and the chef said shall I make you a sandwich, and that was lovely of him’. The chef stated that the home had an environmental health officer visit approximately six months ago and no requirements were made. Boughton Hall DS0000013570.V345998.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 good. This judgement has been made using available evidence including a visit to this service. The people who use the service are protected by the home’s complaints policies and safeguarding procedures. EVIDENCE: The home has a complaints policy which is displayed. It clearly identifies who the people who use the service can complain to. It contains the old office address of CSCI but the manager stated that this would be changed immediately. The manager keeps a complaints log but has received no complaints this year and no complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. The home also has a comments, complaints and suggestions book for all visitors to the home to use and any problems noted here have outcomes clearly identified with actions taken. Nothing has been entered since 2006. The manager stated that all staff have training in safeguarding adults and this is repeated every year and the local authority’s procedures is followed. We found that the home also has their own policy but it is not in line with the local authority’s, therefore a recommendation will be made for the home to change their policy. The home has not had a safeguarding incident in the home since the last inspection. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a well-maintained environment, which was clean and hygienic. EVIDENCE: The home was clean and tidy and well maintained. There is communal accommodation provided which includes two large lounges, two large dining rooms and an activities room. There is a conservatory designated as the smoking area, which is well ventilated and deodorised. The home is in the process of decorating a room in the house specifically for the smokers in line with the new legislation and this will be called the library. Furniture was arranged to provide comfortable informal seating areas. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 16 All bedrooms are single en-suite and those visited had been personalised by the individuals. One visitor in the home stated ‘I can’t say a bad word, her room is lovely and clean and we are so glad we found this home’. Another individual stated ‘my room is lovely and it’s really homely with all my bits around me’. Following the last inspection we were told that the upstairs was about to be decorated and this is now planned and about to take place the manager told us. The radiators upstairs in the corridors are also not covered and this is also part of the refurbishment programme. It is recommended that environmental risk assessments be carried out on the uncovered radiators until the refurbishment has been completed this year. We met with the head housekeeper who was supervising the laundry that morning. She explained she was responsible for all the ordering of supplies in her department. The home has a laundry where all the washing machines are housed and a separate room next door for drying, ironing and where the clean clothes are hung until they are distributed to the individual rooms. The head housekeeper had knowledge of infection control procedures and it was observed that the home had plenty of hand washing facilities. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of people who use the service. EVIDENCE: The manager showed us the current staff rotas, which demonstrated that the home had sufficient staff on duty to manage the assessed needs of the people who use the service. The manager stated that staff numbers are increased whenever necessary, but particularly if staff are providing an escort to an individual attending an appointment or an outing has been arranged. The manager also ensures that there is a good skill mix of staff. The manger told us that all care staff have the National Vocational Qualification (NVQ) or are studying for it now. The training can take place at the home and it was also observed that the home’s induction for all staff is also linked to a national induction programme. We sampled three recruitment folders and a discussion then took place with the manager about pre-recruitment checks that take place. One folder sampled did not contain the reference from a previous work place, which was a care establishment, and staff employed on a working holiday visa did not come with police checks from their country of origin, and therefore recommendations Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 18 have been made at the end of the report. It is also recommended that the application form be amended to allow staff to give a full employment history which allows them to explain any gaps in this history. The home has a training manager who works part time. The training records were shown to us that demonstrated the training that has taken place for all staff including the mandatory training which, the manager stated, was manual handling, safeguarding adults and fire awareness. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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 good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness, and has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: A requirement was made at the last inspection that the registered person must appoint an individual to manage the care home and this process had begun. On the day of the site visit the manager stated that he had given his notice to pursue another career and they were about to inform the staff. The manager stated that the finance manager for the group will act as the manager and the deputy will be covering the clinical areas. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 20 The manager showed us the last quality audit that took place in the home at the end of 2006. This survey had been analyzed and action plans completed for any shortfalls. It is a recommendation that the home also seeks the views of other visiting professionals. Personal finances are not managed by the service and items such as newspapers, hairdressing and chiropody are inclusive of fees. The manager stated that petty cash is kept in the safe and if individuals wish to have cash they can give the home a personal cheque or have money which will then be invoiced monthly. The home also has a safe where individuals can deposit articles for safekeeping, and this is all documented. The manager demonstrated to us that the home has current certificates in place regarding health and safety. The gas, heating system and electrical circuits all have a current certificate. We observed during a tour of the building that the home’s fire fighting equipment was also recently checked. Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 22 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 OP1 Regulation 5 and 5A Requirement The manager to forward to CSCI the service users’ guide when the home has completed the rewriting of this document. Timescale for action 23/09/07 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 OP18 Good Practice Recommendations It is recommended that the home adjust their local safeguarding adults policy to be in line with the local authority’s procedures. It is recommended that environmental risk assessments be carried out on the uncovered radiators until the refurbishment has been completed this year. It is recommended that the home obtains the reference for one particular member of staff who has worked in a care environment previously. 2. OP25 3. OP29 Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 23 4. OP29 It is recommended that the home consult with the appropriate organisation to clarify the checks that are needed for those members of staff on a working visa. It is recommended that the application form be amended to allow staff to give a full employment history, which allows them to explain any gaps in this history. It is recommended that the quality audits also include visiting healthcare professionals and other stakeholders in the home. 5. OP29 6. OP33 Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Boughton Hall DS0000013570.V345998.R01.S.doc Version 5.2 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. 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