Archived: Boscobel

Boscobel is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Boscobel provides accommodation and personal care for up to 20 people with learning disabilities. It is a large Victorian property with accommodation located over three floors. A ramp and steps provide access to the front of the building. The upper floors are accessed via staircases. There is a dining area to the ground floor and a lounge. A garden area is located at the rear of the building and parking at the front. At the time of the inspection 13 people were living at the service.

A registered manager was in post. The registered manager was not available on either day of the 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 2008 and associated Regulations about how the service is run.

Following the last inspection in May 2017 the provider submitted an application to cancel the registration at Boscobel. At the time of this inspection the application was under consideration by the Commission.

At the last inspection in May 2017 we identified breaches of the regulations in relation to; person-centred care, dignity and respect, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, good governance, staffing, fit and proper persons employed, requirements as to display of performance assessments and notification of other incidents.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when. As part of this inspection, we checked whether the actions identified in the provider’s action plan had been completed.

There was no evidence that risks had been reviewed in accordance with the provider’s action plan. The failure to review risk meant that the service could not be certain that people were protected from avoidable harm.

Recruitment practices had not been improved as required.

Applications to deprive these people of their liberty had not been submitted in accordance with the Mental Capacity Act 2005. This meant that people were at risk of being unlawfully detained.

There was no record to indicate that their competency had been checked in accordance with the principles of the Care Certificate. This meant that the service could not be certain that they met the required minimum standards and were able to deliver safe, effective care.

We found that health action plans were not consistently completed and one person’s record showed no evidence that a serious health condition had been reviewed.

None of the six plans we checked had been recently reviewed. This meant that the provider could not be sure that people’s care needs were accurately reflected in the records.

We looked care records and saw evidence that person-centred plans had been developed for some people. Where they had been fully completed they contained detailed information for staff about people’s histories, likes, dislikes and goals. However, of the six care records we saw, only four had a completed person-centred plan.

At the last inspection we identified that safety and quality audits had not been effective in identifying issues and driving remedial action. The records that we saw indicated that some progress had been made and that audits were now more extensive. However, there was no structured audit or oversight at provider level.

Improvements had been made to medicines’ management and medicines were safely managed in accordance with best-practice guidance.

At the last inspection the general level of cleanliness in the home was poor. As part of this inspection we checked to see if the necessary improvements had been made and sustained and found that they had been.

Staffing numbers were adequate to meet the needs of people living at the service. A minimum of three care staff were deployed on each daytime shift. This reduced to two waking staff overnight. Additional staff included a cook, a domestic and an administrator.

People spoke positively about the provision of food and drinks and were given a choice of meals.

We spoke with two visiting healthcare professionals about the quality of communication and support provided at Boscobel. Each person spoke positively about the timeliness of communication from staff and the effectiveness of staff support in following treatment plans. We were given examples where people’s health and wellbeing had improved following good partnership working with healthcare services. For example, one person had regained their mobility following a course of treatment.

Staff told us that they received regular training and supervision and felt supported by the registered manager and senior staff. We saw from records that the majority of staff had been given formal supervision since the last inspection.

People spoke positively about the staff and their approach to the provision of care. It was clear from our observations that staff knew people well and were able to respond to their needs in a timely manner.

People had access to a range of activities within their own homes and communities. Staff provided additional support as required. Activities included; watching television, movie nights, singers and crafts.

People’s rooms were personalised with personal items and family photographs. The rooms that we saw were decorated in different styles and colours and furnished to a basic standard.

The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special

measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

You can see what action we told the provider to take at the back of the full version of the report.

Boscobel provides accommodation and personal care for up to 20 people with learning disabilities. It is a large Victorian property with accommodation located over three floors. A ramp and steps provide access to the front of the building. The upper floors are accessed via staircases. There is a dining area to the ground floor and a lounge. A garden area is located at the rear of the building and parking at the front. At the time of the inspection 13 people were living at the service.

A registered manager was in post. 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.

At the last inspection in November 2016 we identified a number of breaches of regulation in relation to safe care and treatment. We issued a warning notice to the provider which required the service to be compliant with regulations by 9 December 2016. We received assurances from the registered manager and one of the owners that the actions required by the warning notice had been completed. As part of this inspection we checked to see if the necessary improvements had been made and sustained.

One requirement of the warning notice related to a failure to have the safety of the electrical installation checked as required by law. This failure had exposed people to unnecessary risk. We were provided with a copy of the electrical certification and saw that it was dated 17 February 2017. This check should have been completed by 9 December 2016.

A further requirement of the warning notice related to the monitoring and control of hot water accessible to vulnerable people. The water temperatures were checked again at two separate outlets and neither was found to be excessively hot. However, the registered manager was unable to provide any evidence that the temperatures had been regularly checked as required. They subsequently confirmed that the temperature control valves previously discussed had not been installed.

At the last inspection we saw evidence in care records that risk was not fully assessed or regularly reviewed. The review of risk was made a requirement of the warning notice. During this inspection we checked care records for evidence that risk had been reviewed as required. None of the records that we saw on this inspection showed any evidence of review after 30 August 2015.

Records relating to stock levels of a controlled drug were found to be inaccurate. An audit of medicines had failed to identify the error.

At the last inspection we found that some staff had not been safely recruited. On this inspection we saw that sufficient improvement could not be evidenced and the service was in breach of regulation.

As part of the inspection we were shown around the building and made use of some of the facilities. We saw that the general level of cleanliness was poor.

We saw that the action plan produced following the inspection in November 2016 had not been completed as required. This was also the case with the action plan produced following the previous inspection in March 2015. In addition, the service had failed to meet the requirements of the warning notices issued in November 2016. Other measures to monitor safety and quality were inadequate.

The service was not displaying the ratings from the previous inspection and notifications to the Commission had not been submitted as required.

New staff had not completed a formal induction nor had their competency assessed in-line with the requirements of the Care Certificate.

Paperwork relating to the deprivation of liberty safeguards had been started in January 2017, but had not been completed or returned. This meant that people were at risk of being unlawfully detained.

In the four complete care records that we saw, one care plan had been reviewed since the last inspection. We spoke with the registered manager about this who confirmed that the care plans had not been reviewed as indicated in the action plan. This meant that the service could not be certain that plans were safe or effective in directing staff. The service remained in breach of regulation in this regard.

At the previous inspection we identified a concern because staff were not receiving regular supervision. We saw from records that the majority of staff had been given formal supervision bi-monthly in 2017 and that other dates (including annual appraisal) were booked.

People spoke positively about the provision of food and drink. People were asked each day about their preference by a member of staff. Each of the people that we spoke with confirmed that they could ask for an alternative. People told us that they were offered plenty of drinks throughout the day.

At our inspection in November 2016 we identified a concern that records relating to healthcare appointments had not been kept up to date. We saw that information regarding healthcare remained disjointed and difficult to track, but we saw good evidence of people being encouraged and supported to access healthcare services. A visiting healthcare professional spoke very positively about the quality of communication and the positive impact that staff have had on people’s treatment plans. The majority of the records were sufficiently detailed. However, two records contained confusing information. We made a recommendation regarding this.

We were told and saw that there were more activities available to people living at Boscobel. The service was able to demonstrate that sufficient improvement had been made to meet requirements and was no longer in breach of regulation in this regard.

Information regarding compliments and complaints was displayed in the main hallway. The people that we spoke with said that they knew what to do if they wanted to make a complaint. The registered manager confirmed that there had been no formal complaints made since the last inspection.

At the last inspection we saw that policies and procedures were significantly out of date and ineffective in the provision of guidance for staff and managers. Since the last inspection the provider had purchased a comprehensive set of policies and procedures which provided detailed and specific guidance. The staff that we spoke with were familiar with the new policies and procedures. The service was no longer in breach of regulation in this regard.

At the previous inspection the registered manager was unable to provide a significant amount of information and evidence on request. We saw that systems for managing important information were not effective. As part of this inspection we checked the storage and administration arrangements and requested important information. Improvements had been made to systems and the registered manager was able to provide the majority of information on request. The service was no longer in breach of regulation in this regard.

People living at the service and staff were consulted about the service through resident and relative meetings and staff meetings. We saw evidence that information was provided at these meetings and people’s views were sought. For example, at one meeting suggestions were made for changes to the menu. We saw that these changes had been implemented.

The overall rating for this provider is 'Inadequate'. This means that it remains in 'Special

measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

We are considering our regulatory response.

Boscobel provides accommodation and personal care for up to 20 people with learning disabilities. It is a large Victorian property with accommodation located over three floors. A ramp and steps provide access to the front of the building. The upper floors are accessed via staircases. There is a dining area to the ground floor and a lounge. A garden area is located at the rear of the building and parking at the front. At the time of the inspection 13 people were living at the service.

A registered manager was in post. 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.

Measures to protect people from the risks associated with fire were not robust. We saw that a fire door did not close properly and the testing of emergency lighting and alarms had not been conducted by the provider.

Essential safety checks, for example, gas safety and electrical safety had not been completed and actioned as required.

We saw evidence in care records that risk was not fully assessed or regularly reviewed. This meant that the service could not be certain that information relating to individual risk was current or that risk was being safely managed.

The temperature of the hot water was excessive and had not been tested meaning that vulnerable people had access to hot water at potentially dangerous temperatures.

People’s medication was not always stored and administered in accordance with good practice. The medicine’s trolley where the majority of medicines were stored was not secured to a wall or in a locked room as required. This meant that the medicines were more vulnerable to theft. In addition, medicines requiring refrigeration were stored separately in a domestic fridge which was not operating correctly.

The service was not adhering to the principles of the Mental Capacity Act 2005 (MCA). At the inspection in March 2014 we found that the service was not obtaining people’s consent for some important decisions. For example, to manage money on their behalf. We made a recommendation regarding this. During this inspection we found that records relating to consent remained inconsistent and did not clearly demonstrate that consent had been sought or given in relation to all aspects of care.

Following our inspection in March 2015 we made a series of recommendations to improve practice. The service provided a 16 point action plan which sought to address issues arising out of the inspection. At this inspection we checked to see what progress had been made in these areas. We saw that the action plan had not been completed as required.

Safety and quality audit processes were not regular or robust. The provider was unable to demonstrate effective oversight of the service and had failed to identify a number of issues of significant concern over a prolonged period.

The home had an extensive set of policies and procedures. Policies included; adult safeguarding, MCA and person-centred care. Policies were detailed and offered staff guidance regarding expectations, standards and important information. However, the majority of policies that we saw were not in any recognisable order and showed no evidence of review since they were printed in 2009.

You can see what action we told the provider to take at the back of the full version of this report.

Staffing numbers were adequate to meet the needs of people living at the service. A minimum of three care staff were deployed on each daytime shift. This reduced to two waking staff overnight.

We saw evidence that the majority of staff were recruited following a robust procedure. Three of the four staff records that we viewed contained two references, photographic identification, an application form and evidence of on-going training. However, one record for a long-standing member of staff did not contain any evidence of references, an application form or identification. There were Criminal Records Bureaux (CRB) or Disclosure and Barring Service (DBS) numbers and proof of identification on each file. DBS checks are completed to ensure that new staff are suited to working with vulnerable adults. However, there was no system in place to establish if the DBS status of staff had changed since the original application. Some the checks were in excess of 10 years old. This meant that the service could not be certain that its staff were not barred from working with vulnerable adults.

Staff were able to explain how they helped keep people safe and made appropriate reference to training, monitoring and safeguarding procedures. The training records showed that all staff had received recent training in adult safeguarding.

People told us that they felt the staff were competent to deliver their care. The staff that we spoke with were very positive about the training that they received and told us that they felt well-equipped to meet people’s needs.

Staff told us that they received supervision and an appraisal from senior staff or the registered manager. We saw evidence that some meetings had taken place and that important information had been shared. However, formal supervision had not taken place in accordance with the provider’s policy.

As part of the inspection process we checked the kitchen, food storage areas and the dining room. We also spoke to people about the food drinks available. People told us that they enjoyed the food at Boscobel and that they were offered choice.

Records indicated that the majority of people saw healthcare professionals and attended appointments with the support of relatives and staff. However, one record contained a document titled ‘annual health check’ dated October 2013. There was no other record that health checks had been completed subsequently.

We have made a recommendation regarding this.

At the inspection in March 2014 we found that the building was not adapted to meet the needs of older people or those with mobility difficulties. During this inspection we checked to see what adaptations had been made and what positive impact this had on people living at Boscobel. We saw that no significant adaptations had been introduced since the last inspection. However, we saw that people were able to use the building independently and that there had been no negative impact on them.

Information relating to Boscobel was primarily provided in written form. Some documents had been produced using more accessible forms of written communication. For example, words supported by pictures, but these were not common and the images did not always match the written words. This meant that people living at the service may not be able to understand some important information.

Throughout the inspection we saw staff engaging with people in a positive and caring manner. Staff spoke to people in a respectful way and used positive, encouraging language. Staff took time to listen to people and responded to comments and requests. We saw that staff had time to speak with people as well as completing their care tasks. Staff demonstrated that they knew the people living at Boscobel and accommodated their needs in the provision of care.

People living at Boscobel were encouraged and supported to be as independent as possible. The service included three semi-independent units which offered people greater independence and the opportunity to develop new skills.

We saw that some people had signed documents indicating their involvement in the production of care plans. However, the evidence that people or their relatives were involved in regular reviews of care was weak. Records did not contain care plans covering all aspects of care and in some cases were limited to medical needs.

We saw from care records that some people’s personal histories and preferences were recorded. Staff were able to tell us about other people’s personal histories, care needs and preferences, but this information was not readily accessible with care records. This meant that new staff would be reliant on more experienced staff to provide them with important information.

We saw no evidence of regular activities for people living at Boscobel. We asked the registered manager to provide us with an activities schedule, but this was not produced. We spoke with staff and people living at the service about activities and it was clear that some people did not have regular, structured activities.

People’s rooms were personalised with personal items and family photographs. The rooms that we saw were decorated in different styles and colours and furnished to a basic standard. One room had a noticeable malodour which spread to the hallway and other shared areas during the inspection.

The registered manager, director and senior carers dealt with the questions and issues arising out of the inspection process openly and honestly. However they were unable to provide a significant amount of information and evidence on request. We saw that systems for managing important information were not effective.

People living at the service and staff were consulted about the service through resident and relative meetings and staff meetings. We saw evidence that information was provided at these meetings and people’s views were sought. However, ‘resident meetings’ did not provide any clear feedback to people about the results of issues raised at previous meetings.

People spoke positively about the registered manager and the quality of communication they provided. The registered manager was recently appointed and had a good understanding of their role and responsibilities in relation to their registration. However, the service was not displaying its current inspection rating as required.

The overall rating for

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, spending time with people who lived at the home, talking with their relatives, staff providing support, talking with health and social care professionals and looking at records.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We found there were sufficient numbers of staff on duty to meet the needs of the people living at the home.

Recruitment practices were not safe as the provider was unable to demonstrate that checks had been undertaken to ensure staff were of good character and suitable to work with vulnerable adults. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

The home protected the rights and welfare of the people in accordance with the Mental Capacity Act (2005). At the time of the inspection nobody who lived at the home was on a Deprivation of Liberty Safeguards (DoLS) plan. The Mental Capacity Act (2005) is legislation to protect and empower people who may not be able to make their own decisions, particularly about their health care, welfare or finances. DoLS is part of the Mental Capacity Act and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.

Effective arrangements were not in place to ensure the people living there were protected against the risks of receiving care and support that was inappropriate or unsafe. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service effective?

People living at the home were supported to maintain good health and had access to a range of healthcare services when they needed it.

Staff had the knowledge and skills to ensure people living at the home received care and support that was effective and individualised.

Effective arrangements were not in place to ensure staff were appropriately supported through the provision of supervision and appraisal. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service caring?

During the inspection we observed staff supporting people with their individual needs in a dignified and respectful way. People told us they liked living there and that the staff were friendly and nice.

Is the service responsive?

The care records we looked at were personalised to take account of each person's individual needs and preferences. We observed staff providing personalised care to people during the inspection.

The manager had addressed concerns and requests raised by people living at the home through the annual feedback questionnaire and 'residents' meetings'.

Is the service well-led?

Processes were in place for people living at the home to express their views about the quality of the service. These included meetings for people living at the home and an annual feedback questionnaire.

Systems were in place for regularly monitoring the quality of the service. They included audits carried out each month to check issues such as care plans, medication and staffing.

The Care Quality Commission (CQC) had not always been notified of incidents as required in accordance with regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

The people we spoke with were positive about the care and support they received. They told us the staff were supportive and respectful of their choices. They said they could decide how to spend their day and staff respected their decisions. One person said, 'We do respect the home and the home respects us. If the staff have any free time they spend quality time with us.'

People told us they were encouraged to be independent. A person told us, 'I am independent; I do my own washing and [manage] my own medication. I keep it locked up in my room and the staff check each week that I have taken it.' People described a wide variety of community activities they were involved with. Some of the people had jobs in the local community, which they enjoyed and valued.

The majority of people were satisfied with the choice of meals and said they got plenty to eat and drink. A few people said they would like more to eat and the manager agreed to talk with them about this.

The care and support documentation we looked at was centred on the person. It included sufficient detail for staff to understand and respond to a person's individualised needs.

We found that effective recruitment processes were in place.

During this inspection we spoke with two people who told us they liked living at Boscobel. One person told us they had lived there a long time and said 'it is a good place' and 'they [the staff] are nice to me'.

We had a look around the building and observed that the shared areas, main kitchen and bathrooms were clean, tidy and odour free. Arrangements were in place to monitor the cleanliness of the environment. In addition, the health and safety of the environment had been checked each month.

Care records for people living at Boscobel had been reviewed and revised to reflect people's current needs.