Boroughbridge Manor and Lodge 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.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of legal regulation in relation to sufficient staffing.

This service scored 59 (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.

Safety incidents were always reported, thoroughly investigated and monitored. This information was used by managers to learn lessons, which were shared with staff in regular supervisions and meetings to reduce the risk of them happening again.

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.

Thorough pre-admission assessments were undertaken. The registered manager had implemented a robust checklist which clearly set out what actions should be taken before a person moved into the service and immediately afterwards. This meant staff had clear guidance to follow, with specific timeframes, and people’s needs were understood and met as soon as they were admitted to the service.

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.

People told us they felt safe. Comments included, “I feel safe with everybody around and they (staff) are friendly”, “I feel safe. They (staff) do things in the proper way; they do a good job” and “I’ve always felt safe here.” Staff received training about safeguarding and incidents were reported appropriately, monitored and actioned as required. Where people did not have capacity, the service had ensured there were minimal restrictions on their freedom and had made appropriate applications to Deprivation of Liberty Safeguards (DoLS).

The provider did not always work well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risks relating to people were generally assessed and managed to ensure people were safe. These were regularly reviewed and when any changes occurred. However, in some instances for example, where people required bed rails the information in care plans was not always consistent about why they were needed. This meant risks were not accurately identified. Where people were deemed to have capacity they were not always appropriately informed of risks or involved in how these could be mitigated. The service had not always adequately worked with people to understand their distress. We discussed this with the provider and the registered manager who provided assurances after the inspection about the actions they had taken.

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

People were cared for in a safe environment. Robust arrangements were in place for checking both the premises and equipment used to deliver care. However, signage throughout the home was not appropriate to assist people living with dementia to orient themselves. We discussed this with the provider and registered manager who told us a recent provider check had identified this issue and dementia-friendly signage was being sourced.

Personal emergency evacuation plans (PEEPs) contained in the emergency ‘grab’ bag were incorrect because information about people who had left the service was in there. We discussed this with the registered manager who told us the wrong report had been generated. Whilst this was rectified when highlighted it meant in the event of an emergency wrong information would have been used.

The registered manager and staff had undertaken a number of enrichment activities with people to make corridors more inviting for people, for example, by introducing themes, such as gardening or pets and decorating corridors with items relating to these. Whilst this made these corridors more homely we observed it had not helped people to orientate themselves to their rooms.

The provider did not always make sure there were enough staff. However, staff had received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Our observations showed that staffing levels were insufficient to provide adequate support for people. For example, throughout the inspection people were frequently left unattended in communal areas for periods of over 20 minutes in some instances. We spoke with 1 person who confirmed they had not eaten breakfast despite having been supported to get up over an hour and a half earlier. This person told us, “They (staff) will serve us eventually.” Call bells, where people required support from staff, were used regularly throughout the day and were often called repeatedly or left unanswered for significant periods of time, in 1 instance this was for over 5 minutes. The registered manager told us they did not have an automated system in place to monitor call bells but had requested this and was waiting for a system to be introduced. Whilst staff interactions with people were always kind, observations found staff were task focused. For example, there were 10 people in the dining area at lunchtime who had no interaction from staff other than being served their meal.

Consideration had not always been given to effective deployment of staff when changes occurred. For example, 2 activities staff were supporting 2 people to engage in an activity whilst over 10 people were left without observation or support in a communal lounge.

A relative commented, “Sometimes (there are) not always as many staff around as today, but I feel confident with them (staff) and they listen to you.” Staff members’ comments about staffing levels included, “Low staffing can be an issue” and “Staffing needs to improve”.

Staff were recruited safely and new staff had the support of a newly introduced buddy system. All staff received regular training and support.

The provider did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading.

Thorough cleaning schedules were in place. These were regularly completed and checked. However, some areas of the home were not as clean as others. For example, one kitchenette and its associated cupboards, some of which contained food, were observed to be dirty. Food within these had not been stored hygienically. We brought this to the attention of the registered manager who arranged for immediate cleaning and later confirmed this had been completed.

Staff wore appropriate personal protective equipment (PPE).

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People received their medicines as prescribed. Robust governance arrangements were in place to ensure ordering, storage, management and disposal of medicines was within required guidelines. Staff administering medicines were knowledgeable about the medicines administered and were able to tell people what they were for and gently encouraged their administration.