Background to this inspection
Updated
22 November 2023
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 carried out by 1 inspector.
Service and service type
Boughton Lodge Care Home 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. Boughton Lodge Care Home 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, however, they had applied to de-register and the provider had employed a new manager.
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 and professionals who work with the service. The provider was asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does 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 to ask about their experience of the care provided. We also observed the support people received within the communal areas of the home, including the support people received to take their medicine.
We spoke with 11 members of staff including the registered manager, the new home manager, care staff and cleaners. We also spoke with the nominated individual's representative. The nominated individual is responsible for supervising the management of the service on behalf of the provider.
We reviewed a range of records. This included accident and incident records, care and medicine records, audits and 3 staff recruitment files and 2 staff agency files.
Updated
22 November 2023
About the service
Boughton Lodge Care Home provides accommodation and personal care for to up to 19 older people. The service comprises of one adapted building. At the time of our inspection there were 17 people using the service.
People’s experience of using this service and what we found
The provider and registered manager failed to have sufficient oversight of the health and safety of the service. They failed to have systems to monitor and maintain the fire and water safety, gas, electric, equipment and health and safety checks.
The provider and registered manager failed to monitor staff practice in preventing and controlling infection or to monitor the cleanliness of the home; they did not have systems to recognise when improvements were required.
The provider and registered manager failed to monitor recruitment procedures which meant they did not identify they had failed to follow safe recruitment procedures.
People were not always protected from harm and abuse as staff did not always understand how to recognise and report any concerns. The provider and registered manager failed to have systems to monitor and analyse accidents and incidents to gain the insight into trends and patterns to improve the service.
There were not enough staff deployed at night to meet people’s needs or to maintain the health and safety and cleanliness of the home.
People’s risks were not always reviewed when their needs changed.
Although staff had received training, the provider and registered manager did not check staff competencies in safeguarding and medicines management. People did not always receive their medicines as prescribed; the provider audits failed to detect missed medicines.
The provider's and registered manager's pre-assessment of needs was comprehensive and gathered information from relatives and relevant professionals.
People received food and drink that met their needs and preferences.
Staff identified when people were unwell and referred them to healthcare professionals promptly. People were supported to access healthcare appointments when they needed them.
People received care from staff they knew, who were kind and compassionate. People’s privacy and dignity was respected.
People and their families were involved in creating their care plans. People were supported to continue to practice their cultural faiths. People's communication needs were understood and supported.
People and relatives knew how to make a formal complaint. The provider used the information from complaints to review and improve the 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 inspection was rated good, published 12 January 2018.
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.
We have found evidence that the provider needs to make improvements. Please see the safe, effective and well sections of this full report.
We have identified breaches in relation to health and safety, medicines, recruitment and governance at this inspection.
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. You can see what action we have asked the provider to take at the end of this full report.