Boroughbridge Manor and Lodge Care Home

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.

Boroughbridge Manor and Lodge Care Home is a care home providing personal care to up to 77 younger adults and older people, some of whom may be living with dementia or have a physical disability. At the time of this inspection, 62 people were living at the service. The home is purpose built, set over three floors and is located in the Boroughbridge.

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

Improvements had been made since the last inspection. Governance systems were now effective in monitoring the quality and safety of the service and highlighting any areas for improvement.

Risks to people had been assessed, recorded and reviewed on a regular basis. Risk relating to the environment had also been assessed and appropriate maintenance checks were completed on a regular basis.

Medicine were managed and stored safely. Topical medicines now contained opening dates. Staff had completed medicine training and had their competencies in medicine management assessed.

People told us they felt safe living at the service and spoke highly of the staff team and their kind and caring approach. People described how staff promoted their independence and respected their wishes.

Staff had been recruited safely. An appropriate tool was used to calculate safe staffing levels. The deployment of staff was not always effective at mealtimes. The manager took action to address this.

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. Deprivation of Liberty Safeguard renewal applications had not always been made in a timely manner. We have made a recommendation about this.

People were provided with support from appropriate professionals and strong working relationships had been developed. Health passports, which provide important information to other professionals in the event of a hospital admission, were not completed. We have made a recommendation about this.

The home was clean, tidy and well-presented throughout. A recent refurbishment plan had been completed but a dementia friendly environment had not been created. We have made a recommendation about this.

People, staff and relatives spoke positively of the new manager and their approach. Feedback from people and relatives was acted upon and any lessons learnt were shared with the staff team to aid learning and development.

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 9 June 2021) and there were breaches of regulation. 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.

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 Boroughbridge Manor and Lodge Care Home on our website at www.cqc.org.uk.

Recommendations

We have made recommendations in relation to the renewal of Deprivation of Liberty safeguards, dementia friendly environment and health passports following this inspection.

Follow up

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

Boroughbridge Manor and Lodge Care Home is a residential care home providing personal care to 51 people aged 65 and over at the time of the inspection. The service can support up to 77 people in one adapted building.

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

Risk assessments were not always clearly understood by staff to monitor and assess risk. This meant that changes in people’s needs were not reliably monitored. We have made a recommendation about this.

There were gaps in the documentation of medication recording and medication was not always disposed of in line with guidelines. We have made a recommendation about this.

Staff did not always sanitise their hands in-between contact with people living at the service which increased the risk of infection transmission.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Not all staff and people living at the service felt engaged in decisions about the development and changes at the service.

Audits, spot checks and staff supervisions did not highlight issues the inspection team found.

The service had enough staff to meet people’s needs and staff were recruited safely.

People were protected from the risk of abuse or neglect and incidents were raised to the safeguarding authority and Care Quality Commission, when required.

People’s care plans were detailed, and person centred. Staff understood people’s needs and staff had the correct skill mix and experience to complete their roles.

People has choice and control over their meals and drinks and had access to a balanced and varied choice of food. Staff were observed to work well together to ensure people received the help they needed as quickly as possible.

The service welcomed health and social care professionals into the premises to provide specialised health care to people. The premises were decorated to a high standard and it was suitably adapted to meet the needs of people living there.

Staff received feedback from the manager and provider and the service has working relationships with partner organisations and agencies.

Rating at last inspection and update

The last rating for the service under the previous provider was required improvement (published on 19 June 2019). The service remains rated required improvement. This service has been rated requires improvement for the last three consecutive inspections.

At the last inspection the service was in breach of regulation 17 (good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 16 April 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve the quality of medication management.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, effective and well-led which contain those requirements.

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 ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

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

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a continued breach in relation to the management oversight at this inspection.

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

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.

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

We could not be confident people always received their medicines as prescribed because records were not fully completed. The provider had not ensured there was a staff member available who had emergency first aid training to support people in the event of an emergency. People told us they did feel safe.

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 have made a recommendation for the provider to ensure mental capacity assessments and best interest decisions are completed in line with the legislation.

People generally told us they enjoyed the food on offer. People had access to health and social care professionals. Although staff received supervisions and felt well supported, they had not always received specialist training or inductions when they started.

Staff were kind and caring in their interactions with people and upheld their dignity and respect.

At times staff worked in a task orientated way. People told us it was difficult to tell staff what they needed due to their understanding of English. Information about people’s end of life wishes was not always in place. Care plans were in place which guided staff on how to meet people’s needs. A variety of activities were available for people to access.

Checks were completed of the quality and safety of the service, but these had not effectively highlighted the issues we found during this inspection. There was no system in place to look at the overall picture of accidents and incidents within the service to drive improvements.

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

Rating at the last inspection

At the last inspection the service was rated Requires Improvement (report published in April 2018). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach in relation to the governance of the service at this inspection. Please see the action we have told the provider to take at the end of this report.

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 any concerning information is received we may inspect sooner.

Boroughbridge Manor and Lodge is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service supports older people some of whom may be living with dementia and can accommodate up to 77 people.

At the time of our inspection 75 people were living at the service. The service is a large building and people are accommodated over three floors. Each floor is a named unit which has a unit manager who reports to the deputy and registered manager. Each floor had a dining room, seating area and kitchen facilities.

There was a registered manager in post who assisted us throughout the inspection. The registered manager began managing the service in October 2017. 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 2008 and associated Regulations about how the service is run.

Night staffing levels had not consistently met the provider’s own assessment of minimum numbers required. Staffing levels have been reviewed since our inspection to provide the minimum number of night staff together with a redeployment of staff during the day to ensure people with the most complex needs received the support they required.

A fire risk assessment had highlighted actions required to ensure the people who used the service were safe in the event of a fire. Not all of the high risk actions had been completed within the specified timeframe. Since our visits the registered manager has informed us of the progress they have made towards the completion of this work.

Audits were being undertaken by both the registered manager and provider. We identified that timescales for actions required as a result of the audits had not been consistently completed.

The registered manager was in the process of embedding quality assurance processes and was aware of areas to focus on first.

Medicines arrangements were managed safely and health and safety checks were completed.

Staff appropriately recorded and monitored accidents and incidents. We spoke with the registered manager about considering individual patterns and trends in order to address and reduce any potential risks.

Staff understood how to safeguard people from abuse. They received safeguarding training and were aware of signs of abuse and the process to report concerns. The provider had a safeguarding procedure in place and had taken appropriate steps when there were concerns for the safety or welfare of a person who used the service.

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 place in the service supported this practice.

We received mainly positive feedback about the quality of the food and the registered manager listened and responded to people’s feedback. We observed people’s mealtime experience and found while there were some areas for further development overall this was a positive experience.

People were supported to access medical professionals and their health needs were monitored and responded to. We received very positive feedback from healthcare professionals about the service who reported a joint working approach to supporting people.

The needs of people living with dementia had been considered in the design and decoration of the environment.

We observed staff were caring in their interactions with people. They discreetly offered people assistance and were patient in their approach.

Activities were available and the registered manager had recently employed a new activities coordinator to further develop person centred activities.

The registered manager responded appropriately to complaints.

Assessments, care plans and reviews were completed. Care plans were not consistently updated when there had been a change in a person’s needs although staff understood how to support people and delivered person centred care. The registered manager was aware care plans required further development.

We received positive feedback from staff about the support provided by the registered and deputy managers. We observed the management team worked well together and were able to demonstrate how they intended to continuously improve the service. They were responsive and engaging with us throughout our inspection.

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

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

This is a summary of what we found.

Is the service safe?

People were treated with dignity and respect by the staff. Safeguarding procedures were robust and staff understood how to safeguard the people they supported. Systems were in place to ensure that managers and staff learnt from incidents such as accidents. This reduced the risks to people and helped the service to continually improve.

The home had policies and procedures in relation to the Mental Capacity Act (MCA), 2005 and Deprivation of Liberty Safeguards (DoLS). All staff had received training on when a DoLS application should be made and how to submit one. Documentation was available in people's care files to support this.

Staff had received training in all mandatory areas. Staff recruitment procedures were thorough and in accordance with the provider's policy. Staffing levels and experience were based on the individual needs of each person living in the care home. Policies and procedures were in place to make sure unsafe practices were identified so that people could feel protected.

People were being cared for in an environment that was safe, clean and hygienic. Equipment had been well maintained and serviced regularly.

Is the service effective?

People's dietary, mobility and equipment needs had been identifies in care plans. People's needs were taken into account with signage and the layout of the care home, enabling people to move around freely and safely. The building had been sensitively adapted to meet the needs of people with physical impairments.

Staff had the skills and knowledge to meet people's needs. Managers gave effective support to staff including induction training, supervision and appraisal. This was supported by an extensive training programme. The home worked effectively with other agencies and health care services, to ensure a co-ordinated approach to people's care was achieved.

People's end of life care needs had been documented, discussed with people and their families and regularly reviewed and their changing needs had been noticed. Access to palliative care services was provided.

Is the service caring?

People living in the care home were supported by kind and attentive staff. They were cared for sensitively and given encouragement. People's preferences, interests and needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People were involved in a range of activities in and outside the service on a regular basis.

The complaints procedure was understood by staff. The manager was exploring ways of encouraging greater involvement from relatives in the way care was delivered.

Is the service well led?

There was a quality assurance process in place. Records showed that any remedial action needed was actioned promptly. This enabled the quality of service to continually improve. Staff told us they were clear about their roles and responsibilities. All of the staff we spoke to felt they were strongly supported by the managers.

People told us that staff were polite and respectful. We saw staff treating people respectfully and involving people in their care. People generally looked well cared for and had their care needs met. Comments made to us included 'They (the carers) are very good to them, lovely with people', 'They genuinely care', 'The home is very, very good' and 'Quite content'.

We saw that people were provided with choices of food and drink throughout the day. The food was well presented and looked appealing. Staff provided people with assistance and gave encouragement where this was needed. Systems were in place to monitor people's weight and make sure that action was taken if people started to loose weight.

The home was being staffed by an appropriate number of people and the manager was satisfied that staffing levels were sufficient to meet peoples needs. However, a number of people we spoke with felt that staffing levels could be improved and we have suggested the provider keeps this under review.

The home was kept clean and appropriate systems were in place to ensure cleanliness and infection control. There were also regular checks taking place to ensure that the service was being run well and that people were happy with their care.

Overall we judged that the provider is compliant with this outcome area and is generally providing enough qualified, skilled and experienced staff to meet people's needs. All six staff we spoke with told us that staffing had improved at the service and that the management were recruiting new staff and making sure enough staff were on duty, including using agency staff if needed. Staff comments included 'they (staffing levels) are better than they were', 'they have recruited quite a few more and are using agency', 'this weeks been great, fully staffed on all shifts', 'now it's a bit better, getting the right number of staff on duty' and 'numbers have improved.' Staff rotas confirmed that there were usually enough staff on duty.

However, there were areas for improvement that need the provider's consideration. Staff deployment and shift patterns do not always fully meet the needs of the people using the service. For example, staff had been taken off the floor to attend training, but had not been replaced. And staff levels on the top floor did not always recognise the dependency of the people who use the service. Although we did not find evidence of these issues having a negative impact on people during this visit, they have the potential to place people who use the service at risk if they are not addressed.