Archived: Boniface House

Updated 16 December 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was completed by 2 inspectors.

Service and service type

Boniface House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Boniface House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 5 people who used the service and 3 relatives about their experience of the care provided We spoke with 9 members of staff including, team leaders, service manager, senior care staff and care staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included 5 people’s care records and multiple medication records. We looked at 3 staff files in relation to recruitment, training and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

Updated 16 December 2022

About the service

Boniface House is a residential care home registered to provide care for up to 46 older and younger people, some of whom are living with dementia, physical disabilities or sensory impairments. At the time of the inspection 18 people were living in the home.

Boniface House has six separate units, each of which has separate adapted facilities. During the inspection two of the units were not being used.

People’s experience of using this service and what we found

Systems and processes were not always effective in identifying when information was incorrect, missing or conflicting. The provider had multiple auditing processes in place. However, they had not identified the concerns we found on inspection regarding the recording of information.

People’s care plans and risk assessments were not always sufficient to ensure staff had all the necessary information. We found some people did not have risks assessed or mitigating strategies recorded for known risks and some care plans had not been kept up to date.

Unexplained injuries were not always investigated, and some injuries had not been recorded with all the essential information required to ensure staff and healthcare professionals had all the information required to evaluate these injuries.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice.

People were supported by well trained and safely recruited staff. People were exceptionally positive about staff and used word such as, kind, caring, compassionate and lovely when describing them.

Staff felt supported within their roles and enjoyed working at Boniface House. Staff told us they worked well as a team and their wellbeing was considered by management.

Information was shared between staff and management. Regular supervisions and meeting were arranged to share information and give suggestions. Feedback was requested from people, relatives, professionals and staff to support improvements.

People had their needs met. Staff were supportive towards people and encouraged independence. Staff promoted people’s right to dignity and respect. People were able to make choices on gender of staff supporting them with personal care.

People had their healthcare needs met. Staff made referrals to appropriate healthcare support as required. Staff supported people to make and access appointments as needed. Significant people were kept up to date on their loved ones process and any incidents or accidents that may occur.

People were supported to access any religious or cultural community required. People had access to religious services and staff were aware of people’s preferences, needs and wants. Staff encouraged people to participate in hobbies and interests.

People’s communication needs were documented, and staff followed people’s preferred communication method. We observed staff talking to people in a respectful caring manner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

This service was registered with us on 1 April 2021 and this is the first rated inspection.

A focused inspection was completed on 14 April 2022, the service was inspected but not rated. We found the provider to be in breach of Regulation 12, due the provider failing to assess, prevent and control the spread of infections. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulation 12. However, at this inspection we found the provider was in breach of regulation 17.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to oversight and governance at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.