Archived: Boughton Manor

Boughton Manor is a residential care home providing personal and nursing care to up to 27 people. The service provides support to older people, some of whom may be living with dementia. At the time of our inspection there were 26 people using the service.

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

Since our last inspection, improvements had been made to the quality of care people received. Staff had a better understanding of people’s needs, particularly how to communicate and support people who were living with dementia. People were encouraged to socialise with others; where unwilling or unable, they were supported with individual activities to avoid social isolation. Complaints were handled appropriately. End of life care was not currently provided; however, basic end of life care plans were in place. This was an area of care the registered manager was seeking to develop in the coming months.

There had been sustained improvement since our last inspection with a new registered manager coming into post. Breaches from the previous inspection had been addressed and there was a clear structure in place for monitoring risk, assessing staff performance and driving improvement and development.

The registered manager was supported by senior management as well as senior staff within the home to maintain safety and provide people with a calm, happy home to live in. The registered manager understood and adhered to the regulatory requirements of their role.

People were protected from the risk of abuse and neglect. Risks to people’s health and safety were appropriately assessed, monitored and acted on. There were enough suitably skilled and experienced staff to keep people safe. Medicines were well managed. The home was clean and tidy, and measures had been taken to reduce the risk of the spread of Covid-19. Learning from accidents and incidents took place to prevent recurrence.

People received care from staff in accordance with their assessed needs whilst protecting their rights and freedoms. Staff were well trained and supervised. People were supported to follow a balanced and healthy diet. Staff supported people to receive external healthcare when needed. When health and social care professionals came to the home to review people’s care; their recommendations and guidance were followed by staff. The home was well maintained and suitable for people living with dementia. Some of the décor in the home appeared tired and in need improvement.

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 supported this practice.

People were cared for by kind and caring staff. Care was provided in a dignified and respectful way. Where able, people were encouraged to make decisions about their care. Where unable, other relevant people were given the opportunity to contribute to decisions. People’s independence was encouraged.

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

The last rating for this service was requires improvement (published 6 March 2020). 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 regulations.

At our last inspection we also recommended that all staff received sufficient training to provide effective care for all people. At this inspection we found the provider had acted on the recommendation made and they had made improvements.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Boughton Manor on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The provider ensured all visitors to the home provided evidence of a negative LFT result. Professionals were required to provide proof of COVID-19 vaccinations. The home had limited private spaces throughout the home. Therefore, the majority of visits took place in people’s bedrooms.

There were ample supplies of PPE throughout the home. We observed staff wearing PPE as required. Sufficient PPE stations were in place to enable them to don and doff (put on and take off) their PPE safely. Efforts had been made to encourage social distancing. For example, dining tables were limited to two people wherever possible.

The provider had processes in place that ensured the safe admission of new people to the home. Where people were required to isolate, staff, including the activities coordinator were assigned to spend time with them to reduce the risk of loneliness

It was acknowledged isolation for people living with dementia was difficult at times. Increased support from staff was in place where needed. Posters were placed around the home offering guidance and information for people and staff advising them how to spot the signs of COVID-19 and to help to reduce the risk of spreading it.

All staff and people living at the home were tested regularly and in accordance with government guidelines. The provider had ensured staff were fully vaccinated in order for them to carry out their role. Regular cleaning of all touch points and other key areas were carried out throughout the day. The domestic staff had cleaning schedules in place. The quality of their work was reviewed via regular auditing. We observed the home was visibly clean and tidy.

There were normally enough staff to support people safely and to cover any staff holidays, sickness and COVID-19 isolation. Agency staff had been used to cover shifts where needed. The same agency staff were used wherever possible to ensure consistency of care for all.

The provider considered staff member’s wellbeing. A variety of initiatives were in place to thank staff for their support.

The provider had assessed the impact of potential ‘winter pressures’ and acted accordingly. Occasionally, the management staff have supported care staff with their roles when required.

We found the following examples of good practice.

The service had implemented a system for all visitors including visiting professionals. Hand sanitising, a temperature check and personal protective equipment [PPE] were required prior to entering the home. At the time of our inspection the home was closed for all but non-essential visitors.

The registered manager had registered for 'whole home testing' for staff and residents. The registered manager worked closely with external health and social care professionals to ensure all people who tested positive for COVID-19 were cared for safely. Staff were supported to isolate and received ongoing support from the registered manager. Family and friends of people who use the service were regularly updated and the service offered video and telephone calls to all people and their loved ones.

PPE was available and staff wore this in line with current best practice. Further training in infection prevention and control was provided and all staff completed this.

Risk assessments were in place for all staff and people who used the service. Risks associated with COVID-19 were highlighted and the registered manager took action to reduce further risks.

The provider had audit systems in place to provide assurances regarding the cleanliness of the home. Frequently touched areas of the home such as light switches were cleaned multiple times throughout the day.

Boughton Manor is residential care home which provides accommodation for up to 30 people who require nursing or personal care. At the time of the inspection 26 people were living at the home.

People’s experience of using this service:

People did not always receive care and treatment in accordance with their assessed needs, choices and preferences. People’s care records did not always contain an accurate account of the care people received. Staff did not always use people’s life history, personal interests and background to assist them when supporting people who showed signs of agitation or distress. Activities were provided for people, although some people living with dementia were not always engaged within a meaningful and productive way.

Quality assurance processes were not effective in highlighting the inconsistencies with people’s records and the performance of staff in caring for people at the home. Some improvements had been made since our last inspection in the way behaviours that may challenge were managed. However, the actions of staff were reactive rather than proactive, meaning with more initial action from staff the number of incidents maybe reduced.

Care staff were well trained; however, there were gaps in training for some nursing staff. Staff received supervision of their practice, although the effectiveness of these supervisions was questioned by some staff. Medicine management had improved since our last inspection and overall was well managed. However, some handwritten records required double signatures to add another level of checks to ensure the entries were correct. Nursing staff had access to best practice guidelines and standards; however, this was not always implemented effectively in people’s care records. End of life care plan records lacked detail.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. We did note some best interest decision documentation lacked detail about why a decision was made and whether other options could have been considered.

People felt there were enough staff in place to keep them safe and people felt safe when staff cared for them. Staff understood how to identify the signs of abuse or neglect and knew how to act to reduce that risk. People found the staff to be kind and caring and felt they acted on their views. People’s complaints were handled appropriately.

Where people received support with their meals, staff did so effectively and in line with dietary requirements.

The registered manager had a good knowledge of their regulatory requirement to report concerns to the CQC. People told us they would recommend the service to others.

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

Rating at last inspection

The last rating for this service was requires improvement (published 17 January 2019). The service remains rated requires improvement. This service has been rated requires improvement for two consecutive inspections.

We will describe what we will do about the repeat requires improvement rating in the follow up section below.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection improvement had been made in some areas; however, the provider was still in breach of regulations.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Boughton Manor on our website at www.cqc.org.uk

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The home was registered for up to 40 older people. There were 27 people living at the home at the time of the inspection. We were told that the potential shared bedrooms were now used as single occupancy. Everyone living in the care home had a diagnosis of Dementia and required nursing support. There was a complex range of people’s support needs.

At the last inspection, in 22 November 2016, we rated the service as ‘Good’. This inspection was a responsive comprehensive inspection, which means it was brought forward in our schedule due to concerns. These concerns related to a recent Local Authority audit which raised concerns about the service’s management of risk and incidents. Our inspection found similar concerns and we have rated the service as ‘Requires Improvement.’.

During this inspection we found concerns about the management of risk and assessment of mental capacity. We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report. This is the first time the service has been rated as Requires Improvement.

During this inspection we found this service was not consistently safe. Risks associated with people’s behaviour were not managed safely. Behaviour care plans did not contain all the required information to guide staff support. We found staff were responding differently to people’s needs. The registered manager was not aware of this due to staff recording across different forms and these not being audited regularly.

Mental capacity assessments were not always decision specific and people’s rights were not fully protected. Staff training was in date and staff received regular supervision. People told us that they were given choice of meals and said the food was good quality.

There were sufficient staff to meet people’s needs. Recruitment of care staff and nurses was managed safely. People’s physical health needs were clearly assessed and care planned, and medicines were managed safely. We had some concerns about infection control procedures after toileting support.

We found the service was not always caring. Staff interactions were task focused rather than specific to the individual. Staff had variable knowledge on people’s diverse needs, and care plans did not provide sufficient information to support a caring approach. There was evidence of people being involved with care planning. People were treated with dignity and privacy.

Care was not responsive to people’s needs. We saw four people who had experienced incontinence and we needed to prompt staff to support them. We saw minimal activities within the care home and people sat for long periods without engagement. People had been consulted for end of life care planning.

We found the service was not consistently well led. Multiple audits were in place, which had resulted in some improvement. However, audits had not reviewed behavioural support records and this meant we could not be sure people’s needs would be met. We found that risks were not managed consistently or effectively across the service and this had not been recognised by the registered manager. People, their representatives and staff had opportunities to feedback on the running of the service. Visiting professionals told us that the registered manager was always pro-active in responding to concerns.

At the time of our inspection there was a registered manager in place. A registered manager is a person who has been registered with the Care Quality Commission (CQC) to manage the service. Like registered providers they are “registered persons”. Registered persons have the legal responsibility for meeting the requirements of the Health and Social Care Act 2008 and associated regulations about how the service is run.

The service had a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons.’ Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

People were protected from the risk of abuse and staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The registered manager shared information with the local authority when needed and acted on concerns when they were raised to them. Risks to people’s safety were assessed and reviewed on a regular basis. These risks were managed in such a way as to both protect people and allow them to retain their independence wherever possible.

Staffing levels in the service were sufficient and the registered manager regularly reviewed staff levels to ensure that they remained safe depending on the needs of the service. People received their medicines safely from suitably trained staff. Staff had a full understanding of people’s care needs and received regular training and support to give them the skills and knowledge to meet these needs.

People were encouraged to make independent decisions and staff were aware of legislation to protect people who lacked capacity when decisions were made in their best interests. We also found staff were aware of the principles within the Mental Capacity Act 2005 (MCA) and had not deprived people of their liberty without applying for the required authorisation.

People were protected from the risks of inadequate nutrition and dehydration. Specialist diets were provided if required. Referrals were made to health care professionals when needed.

People who used the service, or their representatives, were encouraged to contribute to the planning of their care They were treated in a caring and respectful manner by staff who delivered support in a relaxed and considerate manner.

People, who used the service, or their representatives, were encouraged to be involved in decisions about their care and their environment, and systems were in place to monitor the quality of service provision. People also felt they could report any concerns to the management team and felt they would be taken seriously.

We spoke with the manager, care manager, district manager, four team leaders, two care assistants and two district nurses.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Throughout this inspection we focused on these five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People received care in an environment that was safe. The communal areas, bedrooms that we looked at within the home were generally clean and tidy, although there were some boxes of pads left in a corridor.

We saw people received their prescribed medication and this was handled and stored safely. We observed staff administer people's medication in a safe manner whilst ensuring they respected their wishes and maintained their dignity.

People were supported to move about in a safe manner, using more than one staff member where required and using equipment where needed in a safe way.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. DoLS are part of the Mental Capacity Act 2005. Correctly applied DoLS make sure that people in care homes are looked after in a way that does not inappropriately restrict their freedom. The safeguards should ensure that care homes only deprive someone of their liberty in a safe and correct way, and that this is only done when it is in the best interests of the person and there is no other way to look after them.

The care manager told us there were no people who currently needed a DoLS order, but they would ensure that anyone who did require an assessment, it would be completed and submitted to the authorising body in a timely manner.

Staffing levels had been increased since the last inspection. There were now enough qualified, skilled and experienced staff to meet people's needs and to keep them safe. One person who used the service told us, "I feel safe and they look after me well here.'

Is the service effective?

There were sufficient staff on duty to meet people's needs. A visiting relative said, 'I'm very happy with the staffing at the home. We have built up a rapport with staff, we get information we need from them and they are able to ask us questions about [our relative] and their needs.'

Improvements had also been made in relation to the documentation about the service. We saw an Infection control audit was recently completed at the home, which detailed the necessary changes being made to the service to control the spread of any infection.

People were consulted on decisions relating to their care. People we spoke with felt included and relatives we spoke felt their opinions and views on decisions regarding their family member were welcomed.

One relative of a person who lived at the home told us, 'I can't fault them. New staff have started recently, they all seem to be asking questions about what can they do for the best for [my relative].'

Is the service caring?

We spoke with relatives of people who used the service and asked them if they felt their family member was safe and well cared for by the staff. One person told us, "The last few months have seen a vast improvement. The carers are brilliant, they get on really well with people, and they do seem to really care."

We observed staff interact with people who used the service. They were caring and attentive in their approach and did not rush people. They observed people's dignity and wishes at all times. We observed a person being transferred by hoist to a soft chair in the dining area for lunch. Two staff supported them during hoisting and talked to them to tell them what was happening and offer reassurance and checking the person was happy and comfortable with what was happening.

Is the service responsive?

We saw staff respond to people's needs throughout the inspection. We saw staff responded promptly to people's requests for support. When people needed help, staff were there to assist them.

The management welcomed people's views and responded to them. Questionnaires had been issued to people who used the service and their relatives. The responses received were positive. We saw a person's care records with their known allergies listed. Care plans detailed the list of substances or foods which they were known to be allergic to, with the likely reaction and guidelines for treatment.

Is the service well-led?

We asked people who used the service, their relatives and staff whether they felt the service was well led by the management team. A person who used the service told us, "The new manager seems very nice." A relative we spoke with told us, "I have been impressed with the care they are providing to my relative. The new manager is great, they are always willing to listen to any concerns we have."

We saw improvements had been made since the last inspection. We saw there were now regular audits in such areas as care plans, medication and infection control. Staff spoke positively about the new manager. One staff member told us, 'we've had a lot of changes here, but the new manager seems to be settling things down, we hope they will stay.'

Another member of staff told us they felt listened to, and staff meetings were held to allow staff to express any concerns and share information about the needs of individuals.

People were consulted before decisions about their or their family member's care were made. A relative we spoke with told us, "I am always kept up to date; they (staff) go through the care plan with me.'

People were protected against the risks of unsafe or unsuitable premises.

There were not enough qualified, skilled and experienced staff to meet people's needs. Domestic staff we spoke with told us they could not complete their daily cleaning duties due to the lack of staff. We were told that there were not enough staff working at night to ensure people were kept safe.

Staff were supported in their role. Staff were trained and received regular assessments of their work.

The provider did not always have an effective system to review incidents. Evidence that the provider had requested the views of people who used the service, their representatives and staff on the quality of the service could not be provided.

There was not an effective complaints system available in a format that met people's needs.