CQC report explained · a residential care home
What the CQC found at Boars Tye House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People did not always receive medicines as prescribed. Risk assessments and evacuation information were not always detailed enough, and some possible safeguarding concerns were not reported promptly.
- Effective?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused visit. Its previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- Management oversight did not identify problems with medicines, risk assessments or reporting. The provider did not have effective arrangements to monitor and improve the service.
What inspectors found, August 2022
Boars Tye House was rated Requires Improvement because inspectors found unsafe medicines practices, gaps in risk management and weak oversight.
This was an unannounced, focused inspection on 6 July 2022. Inspectors looked mainly at Safe and Well-led because they had received concerns about safeguarding, risks of harm and medicines. They spoke with people, staff and relatives and checked care, medicines, recruitment and management records.
People said they felt safe and relatives reported no safety concerns. However, some people did not receive medicines as prescribed. One person missed medicine for almost a week and another missed time-critical Parkinson's medicine for three days. Risk information was also incomplete, including information about a pressure ulcer and safe evacuation during a fire.
The home had infection control arrangements, safeguarding training and systems for complaints and feedback. Staff supported people to make choices and worked with health professionals. However, management checks had not found important problems with medicines, risks and reporting possible abuse.
The overall rating fell from Good at the previous inspection to Requires Improvement. The report says no evidence was found that people had been harmed, but there was an increased risk that people could be harmed.
People felt safe
People and relatives gave positive feedback about safety and the staff supporting them.
“I feel safe and happy here, more so than at home.” from the report
Infection control
Inspectors were assured about the home's arrangements for preventing and managing infections, including the use of protective equipment.
“We were assured that the provider was using PPE effectively and safely.” from the report
Choice and legal safeguards
The home was working within the principles of the Mental Capacity Act, with appropriate authorisations in place where needed.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Links with health services
The home worked with several health professionals and made referrals when people needed additional support.
“Information available showed the service worked in partnership with key organisations, such as, GP surgeries, community paramedic who held twice weekly clinics at the service and the Dementia Intensive Support Team and District Nurse services.” from the report
Missed medicines
seriousPeople did not always receive medicines as prescribed. This included time-critical medicine for Parkinson's, which could increase symptoms and falls risk.
“People did not always receive their medicines as prescribed. This placed people at risk and the registered manager had not adhered to the proper and safe management of medicines.” from the report
Incomplete risk information
seriousSome risks were not recorded or managed well enough, including pressure ulcer care and information needed to evacuate people safely in a fire.
“Risks to people's safety and wellbeing were assessed, however not always recorded to ensure risk management procedures were being followed by staff to ensure people's safety.” from the report
Reporting concerns
seriousPossible abuse and incidents involving missed medicines were not always reported to the appropriate bodies promptly.
“Incidents of potential abuse had not always been reported in a timely manner. This placed people at risk of ongoing harm.” from the report
Weak management checks
seriousAudits and other oversight systems did not identify important problems with medicines and risk management.
“However, the provider did not have effective arrangements to assess, monitor and improve the quality of the service.” from the report
Specialist training
needs fixingStaff had mandatory training, but had not received specialist training for some complex needs, including Parkinson's and sexual safety awareness.
“However due to the complexities of some peoples care requirements there had been no specialist training for staff to enable them to support people with more complex needs.” from the report
- 01What changes have been made to make sure time-critical and other medicines are never missed?
- 02How are medicine competency assessments kept up to date for every member of staff who gives medicines?
- 03What detailed risk assessments and evacuation plans are now in place for people with pressure ulcers, mobility needs or other risks?
- 04How are safeguarding concerns and missed medicines reported to CQC and the local authority within the required timescale?
- 05What evidence can you show that the action plan from this inspection has been completed and checked?
This was a focused inspection of Safe and Well-led only; the other key question ratings were carried forward from the previous inspection. This explanation was written from the published report of 20 August 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, March 2022
Boars Tye House was inspected but not rated; inspectors found good COVID-19 controls but an ineffective system for cleaning and infection control.
This was an unannounced, targeted inspection on 14 February 2022. It looked at infection prevention and control during the COVID-19 pandemic, and asked about staffing pressures.
Inspectors found several good measures. These included testing, staff training, safe use of protective equipment, visiting arrangements and a separate four-bedroom isolation area.
However, inspectors were only somewhat assured about the cleanliness and infection control of the premises. Bathrooms, equipment and display areas were not cleaned regularly enough to reduce the risk of cross infection.
The home was inspected but not rated overall. The Safe key question was also inspected but not rated, so this report does not provide a Good or Inadequate rating.
Testing arrangements
The home was following whole-home testing guidance for people and staff, including rapid and weekly staff testing.
“The registered manager was following the governments guidance on whole home testing for people and staff.” from the report
Staff training
Staff had training on working during the pandemic, protective equipment, hand hygiene and infection control.
“Staff had received training on working during the pandemic in relation to COVID-19 and had received training in the correct use of personal protective equipment (PPE), hand hygiene and infection control awareness.” from the report
Visiting support
People could keep in touch through video and telephone calls. The home also arranged visits, including for essential care givers and people at the end of life.
“People were supported to have visitors, and arrangements had been made to facilitate essential care givers and relatives visiting people at the end of their life.” from the report
Isolation space
The home had a separate four-bedroom area where people who tested positive could isolate in a less restrictive way.
“A separate isolation area consisting of four bedrooms enabled people who had tested positive to remain in isolation in the least restrictive way.” from the report
Cleaning and infection control
needs fixingInspectors found no effective system for infection control and cleaning in places such as bathrooms and equipment. Display areas were also not cleaned regularly enough to reduce the risk of cross infection.
“There was not an effective system for infection control and cleaning of the premises, such as bathrooms and equipment.” from the report
- 01What new and more organised cleaning approach was put in place after the inspection?
- 02How do you check that bathrooms, equipment and display areas are cleaned regularly?
- 03What are the current arrangements for testing people and staff for COVID-19?
- 04How can relatives visit, including as essential care givers or when someone is receiving end-of-life care?
- 05How is the four-bedroom isolation area used if someone tests positive?
This was an unannounced, targeted inspection of infection prevention and control and staffing pressures; the service was inspected but not rated. This explanation was written from the published report of 16 March 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Boars Tye House
4 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- August 2022Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2022Inspected but not ratedSafe: Inspected but not rated
- March 2020Goodstayed GoodSafe: GoodWell-led: Good
- August 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- April 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- July 2013
Report published without a new overall rating.
- April 2013
Registered with the Care Quality Commission on 23 April 2013.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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