Boughton Manor Care Home

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. This is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff explained, “If mistakes occur, we're informed through individual or group discussions, and we learn from these incidents,” and “The point of this is not to enforce a blame culture but to learn from this ensuring this does not occur in the future.”

The provider understood their responsibilities under Duty of Candour and relatives confirmed they were kept informed of any incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider had a process in place to ensure continuity of care, if, for example a person was admitted into hospital that the correct information would go with them.

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

Staff were able to clearly describe to us how they would identify potential abuse and what action they would take to escalate this appropriately.

Relatives told us they felt their loved ones were safe at the home. “I am very assured of [Person]’s safety at Boughton Manor,” “[Person] is in the safest place possible,” and “I trust the care staff implicitly.”

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Care plans were detailed with information for staff on how to avoid potential triggers in relation to known risks, for example behavioural or triggers for physical conditions, such as epilepsy. Plans detailed how staff should recognise and support people if they were triggered. This personalised information demonstrated people were at the centre of risk management.

Incidents were analysed monthly by the registered manager to ensure necessary actions had been taken to mitigate against risk. They also kept a clinical risk register to ensure they were monitoring identified risks to people.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The provider kept a home risk register which identified potential risks to the environment, documenting what mitigation was in place and what action needed to be taken. Monthly maintenance audits were carried out to ensure areas such as water temperatures and window restrictors remained safe for people within the home.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The registered manager reviewed peoples needs monthly in relation to the amount of staff required to support them to ensure a safe level of staffing. Through our observations and feedback from staff it was evident there were enough staff to support people in a safe and effective way. Staff said they were able to split themselves well throughout the shift to allow them to complete their tasks as well as spend time with people.

Staff were provided with relevant training and support. Staff told us, “Regular supervisions take place, and I feel supported by management and the entire team.”

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

We observed staff following correct infection prevention measures. We saw staff cleaning people’s hands prior to mealtimes. Staff were trained in infection and prevention control (IPC). Monthly IPC audits were carried out and we observed the location to be clean and well maintained.

Medicines were managed safely. The provider had systems and processes in place to ensure the safe administration and storage of medicines. Staff applied their training to ensure people received their prescribed medicines safely in line with their needs and in line with best practice guidance.

For example, we found staff had access to detailed medicines administration records which recorded the level of support each person needed. We observed where people had been assessed and required their medicines to be crushed, each person had their own tablets crusher in place. This was good practice and protected people from the harm of cross contamination of tablets. Some people required their medicines to be given covertly. Covert administration means people are administered medicines without their knowledge and in their best interest, this is to ensure their health needs were met.

Staff implemented and followed best practice guidance, for example, they ensured the relevant professionals and people’s advocates were involved in discussions surrounding covert administration, staff utilised covert administration as a last resort. This promoted people’s human rights. Staff completed twice daily checks of high-risk medicines which are commonly referred to as controlled drugs, they completed checks to ensure there were no errors or discrepancies in stock. This was in line with best practice guidance.