CARE HOMES FOR OLDER PEOPLE
Boughton Hall Send Marsh Road Send Ripley GU23 7DJ Lead Inspector
Graham Cheney Announced 27 June 2005 10:00 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 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 H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Boughton Hall Address Send Marsh Road, Send, Ripley, Surrey, GU23 7DJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01483 211674 The Old Hall (Send) Co Ltd Charles Patrick Geoghegan CRH Care Home 40 Category(ies) of DE(E) Dementia - Over 65, 4 registration, with number LD Learning Disability, 1 of places OP Old Age, 40 PD(E) Physical Disability - Over 65, 5 Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age range of the persons to be accommodated will be: over 65, one named person may be aged between 60 and 65. Date of last inspection 11 October 2004 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 most 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 H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of Boughton Hall in the CSCI year 2005/2006, which started on 1st April 2005. It was an announced inspection, which meant that residents and staff knew that it was to take place. The inspection started at 9.45 a.m. and finished at 2.00 p.m. The inspector spent time with the registered manager to start with, to get an update on developments with the home and its operation and then met with the catering manager. The inspector then had a tour of the home and spent time talking with residents before lunch. The rest of the time was taken looking at care plans, medication, staffing arrangements, other documents and records. Residents and staff made the inspector very welcome and were happy to talk about life at Boughton Hall. What the service does well:
The home provides a very high standard of accommodation, although some areas needed attention, please see below in the section headed ‘what they could do better’ and the requirements section towards the end of the report. Comments from relatives, residents, general practitioners and other visiting professionals on cards returned to the Commission for Social Care Inspection were generally very positive about the way the home was run and the accommodation. The staff were described as kind, helpful and supportive and the home described as being family run to a high standard. There were some points brought to the management’s attention, please see below. All of the residents who spoke to the inspectors were happy with the service provided. They said that they found the staff kind and helpful, although some residents said that staff seemed very busy and did not always have time to sit and talk. This is common in larger care homes and recognised by the home’s management who generally maintain above average staffing levels to provide a good standard of service. Residents said that they enjoyed the food and some explained that they were offered an alternative if they did not like the main meal. The chef/catering manager was present each lunch time to talk with residents about their likes and dislikes and any concerns. There were indications that food had not been
Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 6 as hot as normal on odd occasions, but this did not seem to be an ongoing issue. In the main residents felt in control of their lives, but some found it difficult having reduced mobility and therefore being more reliant on others for support and going out. Residents said they were happy with the activities and the opportunities to go out and pleased with the home’s newsletter, which kept them up to date with what was happening in the home. All of the residents said they liked their rooms and especially having their own toilet. Some however did not feel it was as good as being in their own home, although most enjoyed having the company of others. Management explained that they run a programme of redecoration with rooms normally being redecorated when vacant. Otherwise rooms were done as required or upon request. The general practice of administration recording and storage of medication was evidenced to be in line with good practice. The only exception was the lack of evidence that medication was checked on receipt. The home’s training manager confirm that all medication was checked on receipt but that this was not recorded. It was a requirement that the home’s policy must be reviewed to ensure that accurate records of medication received on the premises are maintained at all times. What has improved since the last inspection? What they could do better:
The home does not have a visitors’ book as the registered manager wanted the home to feel open and homely to visitors. It was a requirement that this be reviewed with consideration given to fire safety, security and recording official visits. A comment on security at weekends when there was less management and administration staff in the reception area, was made in a comment card returned to CSCI by a relative or visitor. The home’s laundry opens onto an internal corridor and it was a concern to note that a door, which could have been a fire door, had been removed, a second door was wedged open. It was a requirement that these be risk assessed in consultation with the local fire officer and appropriate action taken to ensure fire safety is maintained. Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 7 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. The local environmental health officer should be consulted on the need for fly screens on opening windows and doors in the kitchen area. Some damage was apparent on the wall above the window in room 9, this needs to be made good and redecorated. The registered manager was unable to present any evidence that the two requirements from the last inspection dated 11th October 2004 have been met. “It was a requirement that regular diary entries must be made in the residents’ care plans, which provide evidence to demonstrate that the individual’s holistic needs are being consistently met.” In the care plans sampled on this occasion there were gaps of up to 13 days with no diary entries. Care plans are legally required documents, which provide evidence that the home has made proper provision in meeting the individual needs of residents. Given that on the evidence of this inspection the home appeared to be providing a good standard of care and support it was decided to extend the timescale for compliance. “It was a requirement that a further 10 radiators must be covered within the next two months. These must be identified as those presenting the highest risk to residents.” The registered manager acknowledged that this had not been completed and gave assurances that covers would be fitted over the next two months. Given the overall standard of the accommodation it was agreed to extend the timescales for compliance. Failure to comply with these two requirements within the timescales may lead to further enforcement action being taken. 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 H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 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 standard(s) These standards were not assessed on this occasion. However comments from relatives, residents, general practitioners and other visiting professionals on cards returned to the Commission for Social Care Inspection were generally very positive about the way the home was run and the accommodation. EVIDENCE: Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Evidence gathered from a review of care plans indicated that NMS 7 was not fully met. The shortcomings were first identified at the last inspection; these must be addressed to provide evidence that residents’ needs and wishes are consistently met. A review of medication handling was undertaken and it was concluded that that the systems for the recording of medication received whilst not presenting a high risk to residents’ safety could be improved. EVIDENCE: It was a requirement of the last inspection that regular diary entries must be made in the residents’ care plans, which provide evidence to demonstrate that the individual’s holistic needs are being consistently met. In the care plans sampled on this occasion there were gaps of up to 13 days with no diary entries. Care plans are legally required documents, which provide evidence that the home has made proper provision in meeting the individual needs of residents. Given that, on the evidence of this inspection, the home appeared to be providing a good standard of care and support it was decided to extend the
Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 11 timescale for compliance. Failure to comply with this requirement may result in the need for further action to be taken. The general practice of administration recording and storage of medication was evidenced to be in line with good practice. The only exception was the lack of evidence that medication was checked on receipt. The home’s training manager confirm that all medication was checked on receipt but that this was not recorded. It was a requirement that the home’s policy must be reviewed to ensure that accurate records of medication received on the premises are maintained at all times. Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15 The evidence gathered indicated that these standards were fully met and therefore the home was supporting residents to maintain control and autonomy over their lives as far as they were able. Catering arrangements were commended based on the very positive comments from residents. EVIDENCE: In the main residents felt in control of their lives, but some found it difficult having reduced mobility and therefore being more reliant on others for support and going out. Residents said they were happy with the activities and the opportunities to access the community. They said they were pleased with the home’s newsletter, which kept them up to date with what was happening in the home. Residents said that they enjoyed the food and some explained that they were offered an alternative if they did not like the main meal. The chef/catering manager was present each lunch time to talk with residents about their likes and dislikes and any concerns. There were indications that food had not been as hot as normal on odd occasions, but this did not seem to be an ongoing issue.
Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 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 standard(s) These standards were not assessed; the home has not had any complaints or vulnerable adults concerns. EVIDENCE: Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 23, 24, 25 Overall the home provides a high standard of accommodation well suited to the needs of the residents. The failure to comply with the requirement of the last inspection regarding radiator covers compromises the home’s ability to meet standards 19, 20, 24 and 25 on grounds of potential risk to safety of residents. EVIDENCE: The home provides a very high standard of accommodation; although some areas needed attention, please see below. It was a requirement that a further 10 radiators must be covered within the next two months. These must be identified as those presenting the highest risk to residents. The registered manager acknowledged that this had not been completed and gave assurances that covers would be fitted over the next two months. Given the overall standard of the accommodation it was agreed to extend the timescales for compliance.
Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 15 All of the residents said they liked their rooms and especially having their own toilet. Some however did not feel it was as good as being in their own home, although most enjoyed having the company of others. Some damage was apparent on the wall above the window in room 9, this needs to be made good and redecorated. Management explained that they run a programme of redecoration with rooms normally being redecorated when vacant. Otherwise rooms were done as required or upon request. The home’s laundry opens onto an internal corridor and it was a concern to note that a door, which could have been a fire door, had been removed, a second door was wedged open. It was a requirement that these be risk assessed in consultation with the local fire officer and appropriate action taken to ensure fire safety is maintained. 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. The local environmental health officer should be consulted on the need for fly screens on opening windows and doors in the kitchen area. The home does not have a visitors’ book, as the registered manager wanted the home to feel open and homely to visitors. It was a requirement that this be reviewed with consideration given to fire safety, security and recording official visits. A comment on security at weekends when there was less management and administration staff in the reception area was made in a comment card returned to CSCI by a relative or visitor. Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Evidence gathered during this inspection confirmed that the home meets each of the assessed standards. Staff on duty appeared to be enthusiastic and committed to supporting residents, with training and development being given a high priority. EVIDENCE: In comment cards returned to CSCI the staff were described as kind, helpful and supportive and the home described as being family run to a high standard. All of the residents who spoke to the inspectors were happy with the service provided. They said that they found the staff kind and helpful, although some residents said that staff seemed very busy and did not always have time to sit and talk. This is common in larger care homes and recognised by the home’s management who generally maintain above average staffing levels to provide a good standard of service. Staff training and development were given a high priority with a designated training manager in post. Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 & 38 Evidence gathered during this inspection confirmed that, with the exception of standard 38, the home meets each of the assessed standards and was seen to be well run with sound and accountable management support. Compliance with standard 38 was compromised by the failure to comply with the previous requirement regarding radiator covers, which were a safety risk. EVIDENCE: All of the residents who spoke to the inspectors were happy with the way the home was run and the service provided. As stated there has not been any progress in installing radiator covers to prevent risk of residents being burnt on high surface temperature radiators. In addition there were safety concerns related to the laundry doors being open onto the corridor, etc. Please refer to premises standards.
Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4
COMPLAINTS AND PROTECTION 1 1 3 x 3 1 1 x STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 3 x x x x 1 Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 19 yes Are there any outstanding requirements from the last inspection? 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 12(1)(a) 14(2)(a) 15(2)(b) Requirement It was a requirement that regular diary entries must be made in the residents’ care plans, which provide evidence to demonstrate that the individual’s holistic needs are being consistently met. It was a requirement that a further 10 radiators must be covered within the next two months. These must be identified as those presenting the highest risk to residents. It was a requirement that the home’s medication policy must be reviewed to ensure that accurate records of medication received on the premises are maintained at all times. Some damage was apparent on the wall above the window in room 9, this needs to be made good and redecorated. The home’s laundry opens onto an internal corridor and it was a concern to note that a door, which could have been a fire door, had been removed, a second door was wedged open. It was a requirement that these be risk assessed in consultation Timescale for action Ongoing 27/06/05 2. OP19 13(4)(a) (C) 27/08/05 3. OP9 13(2) 27/07/05 4. OP19 23(2)(b) 27/08/05 5. OP19 23(4)(a) 27/08/05 Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 20 6. OP19 13(4)(a) 23(2)(b) 7. OP19 23(5) 8. OP38 17(2) Schedule 4(17) with the local fire officer and appropriate action taken to ensure fire safety is maintained. 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. The local environmental health officer should be consulted on the need for fly screens on opening windows and doors in the kitchen area. The home does not have a visitors’ book. It was a requirement that this be reviewed with consideration given to fire safety, security and recording official visits. 27/08/05 27/08/05 27/07/05 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 Good Practice Recommendations Boughton Hall H58_s13570_Boughton Hall_v226211_270605_stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection 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
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