Inspection on 31/05/07 for Boulters Lock Residential Home

This inspection was carried out on 31st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Boulters Lock Residential Home 12/12/05

Boulters Lock Residential Home 01/09/05

Boulters Lock Residential Home 03/02/05

Boulters Lock Residential Home 18/11/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Boulters Lock Residential Home 56 Sheephouse Road Maidenhead Berkshire SL6 8HP Lead Inspector Robert Dawes Unannounced Inspection 31st May 2007 10:30 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 DS0000011308.V335818.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. DS0000011308.V335818.R01.S.doc Version 5.2 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 Dementia (7), Old age, not falling within any registration, with number other category (20) of places DS0000011308.V335818.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration to accommodate up to one service user aged 60-65 years old. 12th December 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. Fees range from £650-£795 per week. DS0000011308.V335818.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a routine unannounced site visit, which took place during the day on the 31st May 2007. The pre-inspection questionnaire, one GP’s comment card and three clients’ surveys were returned to the inspector before the site visit. These, together with the site visit, were the main sources of information for the key inspection. During the site visit the inspector interviewed the manager, deputy manager, assistant manager and two senior care assistants; talked with relatives and friends of the clients; discussed the quality of care with three clients; toured the premises; looked at records; case tracked; and observed the interaction between clients and staff. Twenty-one standards were assessed during the site visit of which eleven were met and ten were exceeded. No requirements or recommendations were made. What the service does well: What has improved since the last inspection? What they could do better: The manager intends to produce a development plan that is reviewed every six months and consider having more frequent outings for smaller groups of clients. DS0000011308.V335818.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000011308.V335818.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 DS0000011308.V335818.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): Number 3. People who use the service experience good quality outcomes in this area. No client moves into the home without having had his/her needs assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of three new clients demonstrate that the health and social care needs of prospective clients are assessed prior to their admission. Appropriate admission procedures are in place. DS0000011308.V335818.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Numbers 7, 8, 9 and 10. People who use the service experience excellent quality outcomes in this area. People who use the service have comprehensive and detailed individual care plans, which reflect diversity and cultural needs; their physical and emotional health needs are well met; they are protected by the home’s medication procedures; and are treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the clients’ files seen contained comprehensive and very detailed individual person centred care plans. They are reviewed monthly. Section books are used on a daily basis and contain summaries of the clients’ personal care needs and how each individual wishes these care needs to be carried out. The home operates a key worker system. DS0000011308.V335818.R01.S.doc Version 5.2 Page 10 All the files contained appropriate health records of appointments and charts to monitor weight, nutrition, pressure sores and personal care tasks such as baths, cleaning teeth and washing hair. They showed the clients’ physical health and personal care are being well monitored, responded to appropriately and any problems are being promptly addressed. Clients looked clean and presentable. In response to the question in the GP’s comment card, ‘are you able to see your patients in private?’ and ‘if you give specialist advice is this incorporated into the client’s plan?’ the reply was ‘yes’ to both questions. In response to the question in the clients’ survey, ‘do you receive the medical support you need?’ all three replied ‘always or usually’. A relative said, ‘my mother’s personal health and hygiene issues are addressed promptly’. A client said, ‘my health problems are dealt with well’. To ensure the psychological health of the clients who suffer from dementia is maintained as high as possible the manger has enabled 80 of her staff to undertake dementia training to better understand the condition and respond in a professional manner; ensuring these clients are seen as individuals with strengths as well as weaknesses; focusing on the reality of the person with dementia; and creating a safe and secure environment in which they live. Their care plans contain individual life histories, strengths and abilities assessments and plans to build on their strengths. Outside professional advice is sought in order for staff to respond appropriately to individual emotional problems. None of the clients self-administer their medication. Two members of staff administer controlled drugs. The medication administration records were in order. There are sufficient trained staff to cover all shifts. Appropriate medication policies and procedures are in place. A pharmacist visits the home once a year to inspect the storage, administration, recording and disposal of the medication. In response to the question in the GP’s comment card, ‘is the clients’ medication appropriately managed in the home?’ he replied ‘yes’. Clients can have telephones in their rooms, medical examination and treatment are provided in private and staff use the term of address preferred by the clients. Staff were observed to treat clients with kindness, respectfully and with dignity. In response to the question in the clients’ survey, ‘do the staff listen and act on what you say’ and ‘are the staff available when you need them?’ All three replied ‘yes’. DS0000011308.V335818.R01.S.doc Version 5.2 Page 11 Clients said ‘staff are respectful and kind’. One client said, ‘staff are very patient with the dementia sufferers, staff respond to call bells promptly, has not seen any member of staff being rude to a client and she opens her own post’. Another client said ‘one or two staff have been abrupt with her but generally the staff are delightful, she loves the home and staff treat her well’. The deputy said she was aware of the client’s complaint and had dealt with it. Relatives said, ‘their mother is treated respectfully’. Staff said the manager reinforces the importance of treating the clients as individuals and with respect and dignity. DS0000011308.V335818.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): Numbers 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. The clients’ routines of daily living and activities made available are flexible and varied to suit their expectations, diverse needs and preferences; friends and relatives can visit at any reasonable time; they are helped to exercise choice and control over their lives; and are offered a healthy diet and enjoy their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs an activity coordinator five afternoons a week. Each client has an individual activity plan which is discussed with the activity coordinator and changed to suite the individual needs and wishes of the client. Activities are also discussed at the clients’ association meetings. Activities are displayed on a notice board. DS0000011308.V335818.R01.S.doc Version 5.2 Page 13 The wide range of activities are provided for the clients including gardening, monthly outings in a mini bus (the manager is considering taking smaller groups out more frequently), exercise sessions, quizzes, entertainers, being read to, games and a visiting shop. Clients who suffer from dementia are encouraged to take part in the general activities but staff also enable them to engage in activities which are individual to them i.e. one lady who was a cleaner likes to dust. In response to the question in the clients’ survey, ‘are there activities arranged by the home that you can take part in?’ three replied always or usually. A client said, ‘there are sufficient activities for her to choose from’. A relative said, ‘staff take a lot of time and trouble to find things for my mother to do’. A vicar leads a service in the home once a fortnight and communion is given to Catholic clients. One client said, ‘they get up and go to bed when they wish, stay in own room if they choose, have meals in own room and are free to walk around the home and go out into the garden’. Another client said, ‘she chooses to do things her way, hopes to join an outside choir again which the home is trying to arrange, helps in the garden, and can choose whether to join in an activity’. Staff said if a client wants to go out on their own they can but are are risk assessed first. A relative said, ‘she can visit at any reasonable time’. Clients go out with family and friends. A client said, ‘her friends visit at any time’. The manager conducts the home to ensure clients have as much choice and autonomy as possible. Clients can bring their own furniture and personal effects; have access to their personal records; and manage their own financial affairs as long as they wish and have the capacity to do so. The home employs two chefs who provide a varied, wholesome and nutricious diet for the clients using as much fresh produce as possible. Any type of breakfast (which is up to 11.30), cooked or cold, is offered. There are two choices for dinner and if a client doesn’t like either an alternative will provided. Supper is a choice of a hot snack or sandwiches. Fresh fruit and hot and cold drinks are available throughout the day. Menus are discussed individually and at the clients’ association meetings. A glass of sherry is offerd before lunch and evening meals. Dietary and cultural needs are catered for. DS0000011308.V335818.R01.S.doc Version 5.2 Page 14 In response to the question in the clients’ survey, ‘do you like the meals at the home?’ all three replied always or usually. Clients said, ‘they enjoy the meals, there is choice and plenty of food’. Trained staff stay with clients who suffer from dementia throughout the meal times. DS0000011308.V335818.R01.S.doc Version 5.2 Page 15 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): Numbers 16 and 18. People who use the service experience good quality outcomes in this area. People who use the service feel their views are listened to and acted on; and are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure in place as well as a complaints procedure contained in the clients’ guide. No complaints to the Commission have been made since the last inspection. One complaint has been made to the home since the last inspection, which was responded to appropriately. In response to the question in the service users’ survey, ‘do you know how to make a complaint?’ and ‘do you know who to speak to if you are not happy?’ All three-service users replied ‘yes’. Clients said that if they have a problem they would discuss the matter with staff or the manager. They feel confident it will be responded to. Staff have received training in safeguarding older people. Staff were clear about how to respond to protection issues. No allegations of abuse have been made to the Commission since the last inspection. Safeguarding older peoples’ policies and procedures are in place. DS0000011308.V335818.R01.S.doc Version 5.2 Page 16 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): Numbers 19 and 26. People who use the service experience excellent quality outcomes in this area. The home is comfortable, safe, very well decorated and well maintained. Clients have all the technical aids and equipment to lead as full and independent lives as possible. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is accessible, safe, comfotable, decorated to a high standard and very well maintained. There is a pleasant garden which is accessible to the clents. The dementia unit has a lounge but clients in this unit are free to use the lounge in the main area of the home if they wish. All the bedrooms in the home have en-suite facilities. The dementia unit doors are of a different colour and have large numbers attched in order for the clients to know their rooms. DS0000011308.V335818.R01.S.doc Version 5.2 Page 17 The home is kept very clean and hygienic. Relatives said the home is always clean and free of offensive odours. In response to the question in the clients’ survey ‘is the home fresh and clean?’ all three service users replied ‘yes’. DS0000011308.V335818.R01.S.doc Version 5.2 Page 18 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): Numbers 27, 28, 29 and 30. People who use the service experience excellent quality outcomes in this area. An effective, competent and qualified staff team who receive a broad range of training support the people who use the service fairly, without discrimination and in a caring manner. The home operates a thorough recruitment procedure. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are sufficient staff on duty, during the day and night, to respond to the assessed needs of the clients. There are no vacancies. Staff turnover is low. Agency staff are not used. Staff numbers have increased since the dementia unit has become operational. All staff cover the dementia unit and the general part of the home. In response to the questions in the GP’s comment card, ‘do staff demonstrate a clear understanding of the care needs of clients?’ and ‘are you satisfied with the overall care provided to clients within the home?’ the GP replied ‘yes’. Relatives and friends said,’ the care was very good, staff were helpful, it was a happy home and staff responded appropriately’. DS0000011308.V335818.R01.S.doc Version 5.2 Page 19 In response to the question in the clients’ survey, ‘do you receive the care and support you need’, three replied always or usually. Comments made in the clients’ survey, ‘staff are very caring and patient’ and ‘staff look after my personal care needs well’. One client said,’she had no complaints, was very impressed with the home, staff looked after her well and the home gives good value for the money’. Another client said, ’staff are marvellous’. Staff were observed to treat clients patiently and professionally. 60 of the support staff have achieved a NVQ 2 or above in care. Records showed the home complies with the recruitment regulations. All new staff undertake an induction and foundation training programme. All staff have received basic training and training in key areas of their work such as dementia awareness, palliative care, continence promotion, MRSA and glaucoma. Refresher training of basic areas of work takes place. Staff said they considered training equipped them to undertake their work All staff have individual training profiles which were developed by Skills for Care. DS0000011308.V335818.R01.S.doc Version 5.2 Page 20 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): Numbers 31, 33, 35 and 38. People who use the service experience excellent quality outcomes in this area. People who use the service benefit from a well run home; their views underpin all self-monitoring, review and development by the home; and their health, safety and welfare are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is qualified, competent and experienced to run the home. The manager undertakes periodic training to maintain and update her knowledge and skills. The manager is well supported by a competent and conscientious deputy manager. Staff described the management team as being supportive, approachable, communicates clearly how they want the DS0000011308.V335818.R01.S.doc Version 5.2 Page 21 clients cared for and operates a person centred approach to how the home is run. The home ensures an effective quality assurance and monitoring system operates in the home through regular staff, senior staff, housekeepers’, chefs’ and clients’ meetings taking place; relatives and clients completing an annual satisfaction questionnaire; the manager undertaking a six monthly audit of the home based on the National Minimum Standards; and by ensuring clients’ views are listened to. The manager plans to start developing plans to improve the care provided to the service users which will be reviewed every six months. The manager said she is committed to keep improving the quality of care. The home does not look after any service users’ finances or personal money. There are lockable drawers in every bedroom if clients wish to keep money in their rooms. Records showed all health and safety checks and inspections are up to date and completed as required. Necessary health and safety policies and procedures are in place. There is a home’s fire risk assessment in place. All the clients’ files contained appropriate risk assessments and had been reviewed regularly. All the staff have received the necessary health and safety training including first aid. DS0000011308.V335818.R01.S.doc Version 5.2 Page 22 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 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 DS0000011308.V335818.R01.S.doc Version 5.2 Page 23 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. Refer to Standard Good Practice Recommendations DS0000011308.V335818.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 DS0000011308.V335818.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!