CARE HOMES FOR OLDER PEOPLE
Boulters Lock Residential Home 56 Sheephouse Road Maidenhead Berkshire SL6 8HP Lead Inspector
Yvonne Souden Unannounced Inspection 12th December 2005 02:00 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 Boulters Lock Residential Home DS0000011308.V272644.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. Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Boulters Lock Residential Home Address 56 Sheephouse Road Maidenhead Berkshire SL6 8HP 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) 01628 634985 01628 777808 Boulters Lock Residential Home Limited Mrs Amanda Gardiner Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registration to accommodate up to one service user aged 60-65 years old. 1st September 2005 Date of last inspection Brief Description of the Service: Boulters lock is registered to provide care and accommodation for up twentyseven people, aged sixty-five and over and one person aged between sixty to sixty-five years old, and does not provide a service 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, small mature garden with a patio area and seating that can be accessed from the lounges and dining room. In 2005 the home completed a ten room extension with en-suite facilities, and enlargement to existing dining room and sitting room. The décor and furnishings within the rooms of the extension are of a high standard and a major refurbishment plan within the old part of the building is under way. In all there are twenty-five bedrooms, twenty-three are single and two are double, thus enabling the home to provide a service to couples. Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection assessing key standards that had not been assessed at the previous inspection on the 1st September 2005. It is advisable that the reader reads the previous report dated 01/09/05 to have an overall view of the home’s performance in meeting the ‘Key’ National Minimum Standards within the inspection year 01/04/05 to 31/03/06. At this inspection the inspector spoke with two visitors, six residents, staff and observed the environment and records in place. What the service does well: 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. Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 6 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 Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 7 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): Standards the assessed. EVIDENCE: Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 8 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): 9 Service users are protected by the home’s policy and procedures for dealing with medicines. EVIDENCE: The Inspector assessed medication in areas where requirements and recommendations had been made at the unannounced inspection on the 1st September 2005. Management have reviewed their medication policy to ensure medication is stored safely and securely and that the controlled drug records are accurate. Management ensure service users medication monitored storage boxes, as dispensed by the pharmacist, have a clear identification record that describes the collar and shape of the medication. Management have obtained a copy of the Royal Pharmaceutical Society of Great Britain guidelines on the Administration and Control of Medicines in Care Homes and Childrens Services. Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 9 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Service users are supported to maintain their social, religious and recreational interests and are helped to exercise choice and control over their lives. Service users maintain contact with family and friends and are offered choice from a nutritionally balanced menu plan. EVIDENCE: On the day of the inspection the residents notice board detailed recreational activities available for example, Art & Craft, Step Back in Time, Word Games, Religious Services and an array of Christmas festivities. Discussions with service users and their visitors demonstrate that service users feel supported within the choices they make, and service users individual care plans detail the service users religion and recreational interests. Management confirmed that they plan to recruit an activities co-ordinator in the New Year, however it was evident that the staff rota is arranged to ensure sufficient staff are on shift to support service users within activities and to outings within the community. The Inspector observed positive interaction between staff and service users and observed service users to have the freedom to come and go. Meals are presented attractively from a nutritionally balanced menu plan where choice is evident. At the time of inspection the manager was reviewing the four-week menu plan with an aim to improve the alternative choice available and records kept of the service users choice.
Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 10 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 and 18 Management listen and take serious any concerns raised by service users and their representatives. Service users are protected from abuse but management and staff need to be fully aware of multi-agency procedures in place. EVIDENCE: The home has a complaint policy and procedure and has received one complaint since last inspection dated 06/11/05. The complaint has been noted as resolved within the homes complaint/compliment logbook. Staff have attended basic abuse awareness training within the Royal Borough of Windsor & Maidenhead, and the home uses videotapes to deliver staff induction and staff refresher training on abuse awareness. The home has a whistle blowing policy and has a copy of the DHO ‘A Practical Guide’ on the Protection of Vulnerable Adults Scheme. Management do not have a copy of Windsor & Maidenheads Multi-Agency Policy and Procedures for the Protection of Vulnerable Adults from Abuse, and should obtain a copy to ensure management and staff are aware of the procedure. Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 11 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): Standards not assessed. EVIDENCE: Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 12 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): 30 Staff training records monitor staff training to ensure they are competent to do their jobs. EVIDENCE: The Inspector revisited standard 30 following a recommendation made at the unannounced inspection on the 1st of September 2005. Management have reviewed the individual skill profiles of staff to ensure records are up-to-date on training required, training received and training due. Management have also developed a staff team-training programme that identifies staffs’ mandatory and specialist training needs, training attended and training due. Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 13 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, 35 and 38. The home has a competent manager who ensures service users financial interests are safeguarded, and health, safety and welfare is promoted and protected. EVIDENCE: Staff receive mandatory training/updated training within health and safety, and fire records identify regular safety checks. Servicing of equipment takes place regularly, and service users are protected from risk of scalds/burns as hot water outlets are monitored and radiators covered. Individual service user financial records were observed to be accurate. The home will only keep safe a small amount of the service users money as instructed by the service user or their representative. The manager is competent within her role and has a degree in Health & Social Care, is a Registered General Nurse and has achieved the Registered Managers Award. The manager has quality control systems in place to monitor and improve the service provided.
Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 14 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 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 15 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. Standard Regulation Requirement Timescale for action 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 Management should obtain a copy and the Windsor & Maidenhead Multi-Agency Policy and Procedures for the Protection of Vulnerable Adults from Abuse and should be able to demonstrate their knowledge of this procedure. Boulters Lock Residential Home DS0000011308.V272644.R01.S.doc Version 5.0 Page 16 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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