CARE HOMES FOR OLDER PEOPLE
Boughton Manor Care Home Church Road Boughton Newark Nottinghamshire NG22 9JX Lead Inspector
Karmon Hawley Unannounced Inspection 18th October 2005 09:45 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 Manor Care Home DS0000024632.V260089.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. Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Boughton Manor Care Home Address Church Road Boughton Newark Nottinghamshire NG22 9JX 01623 860436 01623 835968 boughton.manor@craegmoor.co.uk 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) Craegmoor Healthcare Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (40) Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 1 resident 58 years and above Date of last inspection 26th May 2005 Brief Description of the Service: Boughton manor is a converted older property accommodating 37 service users who suffer from dementia type related illness. There are 21 single bedrooms and 8 double rooms of which none have en suite facilities. There are sufficient bath and toilet facilities to meet the needs of current service users. The communal space is ample and the lounge and dining areas are pleasantly laid out, with space for staff to assist service users with their daily needs. The care home has a pleasant outlook with an extensive garden around all aspects of the building, which is wheelchair accessible. Parking is available and there is a bus stop approximately 500 meters from the care home; the local village amenities are about a mile away. The village is within close range to major road networks. Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place in one day and was performed by one inspector. The main method of inspection was case tracking, this is a method of sampling the records of three randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Three service users and two relatives were spoken with during the inspection so as to give the inspector an insight into the conditions and standards within the home. All were satisfied with the care received and the standards within the home. The manager and two staff members were spoken with. Staff were able to discuss core values and principles of care and their job role in meeting service users needs. What the service does well: What has improved since the last inspection?
Several improvements have been made since the last inspection; all requirements set have been actioned and met. A new safe has now been installed and service users personal allowances are kept securely. Two staff members also now sign for all transactions to fully protect service users. Further hand washing facilities are being installed to ensure infection control procedures are at a high standards, thus reducing the risk of infection and cross contamination. The statement of purpose and complaints policy has been updated ensuring service users and relatives have access to up to date information. Risk assessments with regards to entrapment and the use of bedrails now take place, further protecting service users. Care plans are
Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 6 evaluated monthly and are service user focussed and reflect care and condition ensuring needs are fully met. 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. Boughton Manor Care Home DS0000024632.V260089.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 Boughton Manor Care Home DS0000024632.V260089.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): EVIDENCE: Not assessed during this inspection Boughton Manor Care Home DS0000024632.V260089.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): 7,9 Whilst service user health, personal and social care needs are set out in a plan of care further consideration is required with regards to communication and follow up of short term problems, developing risk assessments and ensuring all necessary assessments have taken place to ensure service users needs are fully met. Service users are protected by the homes policies and procedures with regards to medication, however this may be compromised due to minor lapses in communication. EVIDENCE: Three service users case files were examined and demonstrated that various assessments take place with regards to the daily activities of living, manual handling, and nutrition. These had been completed in two files examined however in the case of the third, a new admission, not all assessments had been completed. Care plans in place were extremely in depth, personalised and fully addressed service users needs. There was evidence of in depth reviews taking place and that care plans are updated to reflect changing needs. Whilst risk assessments were in place, within two files examined, which highlighted that physical and verbal aggression was an issue, there were no risk
Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 10 assessments in place. Daily records were maintained and significant events were noted, however in one instance were a specific problem had been queried and the notes stated that a GP visit would be required it took 9 days for the GP to be called and then there was no follow up of this visit and the outcome within the care notes to evidence this had been completed and whether the problem resolved. Medications inspected on the day of admission were satisfactory, medication charts were clear and contained required instructions. An appropriate policy is in place with regards to the medication procedures. The home currently has a contract with regards to the disposal of medicines and this will continue to comply with new legislation. The treatment room has a catch at the top of the door, however the key to the main lock had been lost, therefore due to the inspectors concerns a new lock was fitted on the day of inspection. Oxygen is prescribed to one service user and is stored in her room, however there was no warning sign apparent, therefore this was also actioned. Boughton Manor Care Home DS0000024632.V260089.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): 15 Service users receive a wholesome and appealing balanced diet in pleasing surroundings, however service user safety may be compromised due to the lack of hazard analysis in place. EVIDENCE: A well balanced diet is on offer; service users opinions are considered when the menus are devised. There was evidence that choice is offered and one relative spoken with was able to substantiate this and that meals were at a good standard. Appropriate records were available to demonstrate that cleaning and necessary temperature checks take place. Although it was stated that checks take place when food is delivered and received into the home there were no records to substantiate this. There were no hazard analysis critical control point records available to demonstrate that safety analysis is occurring. The kitchen was noted to be clean and tidy and there was evidence of stock rotation in the storeroom. Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 12 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 Service users and relatives can be assured that complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: There have been no complaint received since the last inspection; the requirement set with regards to updating the complaints policy has been actioned. Staff when spoken with were able to discuss the actions they would take in the event of receiving a complaint. Service users and relatives spoken with expressed no concerns or complaints with regards to the home. Policies and procedures with regards to the protection of vulnerable adults from abuse remain in place as at the previous inspection. 10 staff have now undertaken the relevant training and an additional 8 have been booked onto a course. Staff when spoken with were able to discuss how they would respond to observation of abuse and how they would deal with challenging behaviour. Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 13 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): EVIDENCE: Not assessed during this inspection Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 14 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 The number and skill mix of staff meets service users needs. Service users are in safe hands at all times. EVIDENCE: The staff rotas were observed and demonstrated that sufficient staff are employed throughout the day in order to meet the needs of service users. The manager considers the skill mix when planning the rota and has increased staffing levels of late. Staff when spoken with stated that there were sufficient staff and the staff team worked well together. Four staff have attained their national vocational qualification (NVQ) and two are awaiting certification. Further staff are waiting to commence their NVQ in both level two and three once a provider has been established. New staff employed undergo a recognised induction training programme. Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 15 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): 31,33 Service users live in a home that is run in their best interest and well managed by a competent and accountable manager who is working towards continued development of the home. EVIDENCE: The acting manager has been in post since January 2005, has undertaken the registered manager process and is awaiting certification. She is a registered mental health nurse and has continued to develop herself professionally since registration. She is able to demonstrate knowledge and competence within her job role. Staff spoken with spoke highly of the manager, stating that improvements have been made with regards to standards and communications and that she is approachable. Relatives spoken with also spoke highly of the manager.
Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 16 Quality assurance questionnaires take place twice a year; relatives are invited to assist service users in completing questionnaires and also along with social workers and general practitioners to attend review meetings. Results of questionnaires are sent to the regional office and the manager works with service users and relatives to remedy any concerns if necessary. The manager and regional manager also carry out internal audits, which include, care planning, medication, health and safety, training and accidents. Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X X Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 18 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 Standard OP7 Regulation 14(a) Requirement The responsible individual is required to ensure service users undergo appropriate assessment to ensure that needs are fully assessed. The responsible individual is required to ensure that appropriate risk assessments are in place to fully protect service users. The responsible individual is required to liaise with the environmental health officer with regards to food safety. Timescale for action 26/11/05 2 OP7 13(4,c) 26/11/05 3 OP15 16(I,j) 26/01/06 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 1 Refer to Standard OP 9 OP28 Good Practice Recommendations To ensure appropriate storage of oxygen and that warning signs are posted when oxygen is used within the building. To continue to work towards staff employed completing a National Vocational Qualification in Care.
DS0000024632.V260089.R01.S.doc Version 5.0 Page 19 Boughton Manor Care Home Boughton Manor Care Home DS0000024632.V260089.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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