Boroughbridge Manor and Lodge Care Home

Updated 14 March 2024

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 carried out by three inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Boroughbridge Manor and Lodge 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. Boroughbridge Manor and Lodge 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 on both days.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals 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 9 people who used the service and 5 relatives to ask them for their views on the care they were receiving. We spoke with 13 members of staff including the managing director, registered manager, senior care workers, care workers and ancillary staff. We observed care in the home. 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 aspects of 7 people’s care records and other records relating to the management of the service such as training records and audits.

Updated 14 March 2024

About the service

Boroughbridge Manor and Lodge Care Home is a care home providing personal care to up to 77 people. This includes people living with dementia and those with a physical disability. At the time of this inspection, 63 people were living at the service. The home is purpose built, set over three floors, and is in Boroughbridge, North Yorkshire.

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

Risks to people’s health and safety were periodically assessed. However, care plans were not always kept up to date with the latest information on people’s needs. Care plans were not always subject to meaningful review and evaluation to promote high quality outcomes.

Overall, people and relatives told us that they received good quality care. However, we found inconsistencies in the quality of care and some people living with dementia did not always receive person-centred care and support.

Systems were in place to assess and monitor the service but were not always effective in ensuring a high quality service.

Medicines were managed in a safe way. Safeguarding procedures were in place, and we saw evidence they were followed to keep people safe. However, some staff told us they did not feel able to raise issues with the registered manager. We made a recommendation about exploring the reasons some staff did not feel able to speak up.

There were enough staff to ensure people received a basic level of care although staff were busy and had little time to support high quality person-centred care. We made a recommendation for the provider to review staffing levels in the home.

Recruitment procedures were in place although there was a lack of oversight of recruitment records to ensure the appropriate practices were consistently followed.

People said they enjoyed the food and drink in the home. We found nutritional screening tools were not always used appropriately. We made a recommendation about ensuring these are effectively used.

People and relatives told us they felt involved and consulted in how the home was run. Staff provided mixed feedback about the service; some staff told us they did not feel supported by the management team. Audits and checks took place, although some of these needed to be more robust to help ensure a consistent, high-quality service.

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.

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 good (November 2022).

Why we inspected

The inspection was prompted in part due to concerns received about risk management. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe, effective, and well led only. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘All inspection reports and timeline’ link for Boroughbridge Manor and Lodge on our website at www.cqc.org.uk.

Enforcement and Recommendations

At this inspection we found breaches of regulation relating to good governance and person-centred care.

We made recommendations relating to staffing levels, using nutritional screening tools effectively and ensuring barriers to staff speaking up were explored.

Please see the action we have told the provider to take at the end of this 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.