CARE HOMES FOR OLDER PEOPLE
Boulters Lock 56 Sheephouse Road Maidenhead Berkshire SL6 8HP Lead Inspector
Yvonne Souden Unannounced 1 September 2005 10:00
st 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. Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Boulters Lock Address 56 Sheephouse Road Maidenhead SL6 8HP 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) 01628 634985 Boulters Lock Residential Limited Mrs Amanda Gardiner Care Home - Private Care PC 27 Category(ies) of Old age not falling within any other category registration, with number OP of places Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 03/02/05 Brief Description of the Service: Boulters Lock is a registered care home providing care and accomodation for up to twenty-seven people, aged sixty five and over, who have been assessed as having low dependency needs. The home does not provide a service to service users within any other category of care. The home is a large detached house set within a private residential road, close to a picturesque area by the River Thames, and is close to the amenities that Maidenhead town has to offer. There is parking at the front of the house for several vehicles, and to the rear is a pleasant, mature small garden, with a patio area that can be accessed from patio doors within the lounges and dining room. In 2005 the home increased the number of service users that they can accommodate from 19 to 27 following the completion of a 10 room extension with ensuite facilities, and enlargement to existing dining room and sitting room. The décor and furnishings within the rooms of the extension is of a high standard and a major refurbishment plan within the old part of the building is under way. In all there is 25 bedrooms, 23 are single and two are double, thus enabling the home to provide a service to couples. Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken by one Inspector on a Thursday. The Inspector had opportunity to speak to management, staff and several residents individually and in groups. The Inspector looked at systems in place to protect residents whilst meeting their health and social care needs, and assessed the environment, staffing levels, training and recruitment. What the service does well: What has improved since the last inspection? What they could do better:
The home must review its medication policy to ensure the safe administration of medicines to residents, and should seek professional guidance from information that is readily available when reviewing their policy. Although staff spoke of training received records did not support this and management should implement individual staff skill profiles and a training programme to demonstrate training attended by staff. Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 6 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. Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 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 standard(s) 1 & 3 The homes Statement of Purpose and Service Users Guide needs to be reviewed, but contains appropriate information to ensure prospective service users and their representatives are informed. Service users needs are assessed prior to admission. EVIDENCE: The homes Statement of Purpose (SOP) and Service Users Guide (SUG) was last reviewed in 2002, and has detailed information to ensure prospective service users and their representatives are informed. However, the SOP and SUG should be reviewed to reflect the environmental change that has and is taking place, and of the increase in service user numbers. An error within the SOP summary states that the home provides a service to people over 70 years as opposed to 65 years and over. The registered manager spoke of her plans to review the SOP and SUG on completion of the major refurbishment programme, to ensure they reflect the current status of the home. The files of two new service users demonstrate that the health and social care needs of prospective service users are assessed prior to their admission, and this was further evident from discussions with service users and staff.
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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 The health and social care needs of the service user is met with dignity and respect as is reflected within the service users individual plan of care. The homes policy and procedures for dealing with medicines is not strictly adhered to, putting service users at risk. EVIDENCE: Records viewed and discussions with service users, senior staff and key workers demonstrate that care plans are reviewed regularly, and that staff have an awareness of the needs of the service users and treat them with dignity and respect. A visiting GP and records kept demonstrate that health and social care professional are informed and involved in meeting the health and social care needs of the service users. The manager informed the Inspector that improvements within the format of the service user plan has taken place to improve communication and consistency of care. Care plans viewed identify the needs of the service user and associated risks, with a clear plan of action in place to meet those needs and minimise risk. The home has a medication policy and senior staff have received in-house training. Records show that the home has applied to access medication training provided by the local authority. Errors within the storage of medication and records kept was observed by the Inspector and discussed with
Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 10 management and senior staff. A recommendation and requirement has been made to ensure service users are protected by the homes medication policy. Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 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 standard(s) Standard 12 to 15 were not assessed at this inspection. EVIDENCE: Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 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 standard(s) Standard 16 to 18 were not assessed at this inspection. EVIDENCE: Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 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 standard(s) 19,24 & 26 Service users enjoy having their own possessions in the privacy of their comfortably furnished room, and live in a safe, clean and homely environment. EVIDENCE: The inspector observed that the home was clean and comfortable with systems in place to ensure the safety of service users. The new extension is furnished and decorated to a high standard, and service users voiced their general satisfaction of the improvements made, and of the planned improvements to come within the old part of the building. The Inspector observed the refurbishment plan underway as workmen went about their tasks, without too much disruption to the service users. The home ensures fire safety procedures are in place and are maintained. It was evident throughout the home that staff follow infection control procedures and ensure a high level of cleanliness is maintained within the home. On the day of inspection the Inspector observed service users make full use of the comfortable lounges and patio area that is accessed from the two lounges and dining room, as they listened to music, participated in conversation and were invited to take part in activities delivered by the visiting activity coordinator.
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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, 28, 29 & 30 The homes recruitment policy protects service users, and staff are in numbers and skill mix to be competent in meeting the needs of the service users. EVIDENCE: On arrival at this unannounced inspection, there was a full staff team on shift to meet the needs of 22 service users that equated to the manager, deputy manager, three care assistants, one domestic, a cook and an assistant cook. The Rota identified that from 2 p.m. until 8 p.m. there would be two care assistants plus a manager, and that this increased to three care assistants from 8 p.m. until 10 p.m. Two waking night staff are on shift through the night. Over 50 of staff have a National Vocational Qualification in care and discussions with staff show that they feel supported by management thus ensuring the needs of the service users are met. Management use videos followed by a questionnaire on the video to deliver induction and refresher training within mandatory subjects to staff. Staff attend mandatory training that is delivered by an external trainer but records do not strictly record training received, therefore records would indicate that some staff have not received updated mandatory training. Management have confirmed that they are looking at ways of improving records made and have delegated the task of training co-ordinator to a senior staff member with plans to improve staffs individual skill profile and the overall teams training programme. Discussions with staff and records viewed demonstrate that new staff receive an induction and are recruited following the homes recruitment procedure that ensures security checks are maintained prior to an offer of employment to the prospective staff member.
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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) Standards 31 to 38 were not assessed at this inspection. EVIDENCE: Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 16 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x
COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 17 No 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 9 Regulation 13.2, Sch 3.3 (i) Requirement Management must review their medication policy and procedure to ensure medication is stored safely and securely, and must ensure the controlled drugs record is accurately completed by those staff who have administered the medication. Management must ensure the storage boxes that the service users medication is dispensed into has an identification record that describes the colour and shape of the medication as is the procedure within the system used. Timescale for action 01/10/05 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 9 Good Practice Recommendations To assist management and senior staff in the review of their medication policy and training of staff, management should obtain a copy of the Royal Pharmaceutical Society of Great Britain guidelines entitled The Administration and
H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 18 Boulters Lock 2. 30 control of Medicines in Care Homes and Childrens Services. Management should review the individual skill profiles of staff to ensure records are up-to-date on training required, received and due. For the purpose of inspection by inspectors and managers within the home, management should develop a staff team training programme that should give an updated account of all staffs mandatory and specialist training needs, training attended and training due. Boulters Lock H52-H01 S11308 Boulters Lock V236018 010905 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 2nd Floor, 1015 Arlington Business Park Theale Berkshire RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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