Background to this inspection
Updated
26 July 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 completed by 1 inspector.
Service and service type
Boughton Green Road Limited 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 Green Road Limited 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 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 2 people who used the service and contacted 9 relatives about their experience of the care provided. We contacted 16 members of staff including the registered manager, head of care, clinical head, staff coordinator and care staff. We observed the interaction between people and staff.
We reviewed a range of records. This included 5 people’s care records and medication records. We looked at 2 staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.
Updated
26 July 2023
About the service
Boughton Green Road Limited is a residential care home providing accommodation and personal care to up to 14 people. The service provides support to older and younger people with mental health or physical disability needs. At the time of our inspection there were 14 people using the service.
People’s experience of using this service and what we found
Systems and processes to ensure effective oversight were not embedded and sustained into practice. The concerns we found on inspection had not all been identified within audits and reviews. The provider had implemented new procedures just prior to the inspection.
Not all risks had been assessed or mitigating strategies recorded. Injuries did not always have a reason recorded to identify how the injury had occurred or an investigation to identify the cause and prevent reoccurrence.
Care plans did not always contain up to date, factual information. Staff did not always have the time to read care plans and risk assessments. However, staff knew people well and a team of different disciplines (such as speech and language therapists, Psychology and physiotherapy) supported each person.
People were supported safely with medicines and staff adhered to infection, prevention and control procedures.
People, staff, and relatives felt the registered manager kept them updated on any changes to the service. People, staff and relatives felt able to raise concerns and told us they would be listened to.
Staff felt supported within their roles and felt Boughton Green Road Limited was a good place to work and they met people’s needs.
People’s communication needs were assessed, and strategies implemented to ensure information could be understood by all. Care plans included people’s communication and sensory needs. People were involved in their care and had named staff to support them with specific needs. People celebrated their religion and culture with staff who received equality and diversity training.
The provider and registered manager were committed to learning and improving care. Lessons had been learnt and the registered manager worked with health and social professional to make improvements.
People were supported by staff who were described as kind and caring. Staff promoted people’s independence and respected their dignity. Staff understood a person’s right to privacy and to consent.
People were supported by staff who were safely recruited, had an induction and completed shadow shifts before lone working in the service. Staff received regular supervisions, handovers and meetings to share information and ensure they understood people’s needs.
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
This service was registered with us on 16 May 2022, and this is the first inspection.
The last rating for the service under the previous provider was requires improvement, published on 5 December 2019.
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.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.