CQC report explained · a residential care home
What the CQC found at Boroughbridge Manor and Lodge Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, March 2024
Rated Requires Improvement; inspectors found gaps in care planning, person-centred dementia care and management oversight, with an increased risk that people could be harmed.
This was an unannounced focused inspection on 17 and 21 January 2024. Inspectors spoke with people, relatives and staff, observed care, and checked care records, training records and management audits.
The home kept medicines safely, followed safeguarding procedures and maintained clean premises. However, care plans were not always up to date, staff were sometimes too busy to provide person-centred support, and some staff did not feel able to raise concerns.
Inspectors found breaches relating to person-centred care and good governance. The overall rating changed from Good at the November 2022 inspection to Requires Improvement. The home must send an action plan, and progress will be monitored.
Medicines
Medicines were generally recorded, stored and given safely. Staff were trained and their competence was checked.
“Medicines were managed in a safe and appropriate way.” from the report
Safeguarding
Staff had safeguarding training, and the home had followed appropriate procedures when concerns were identified.
“We saw evidence of appropriate action taken to identify and report safeguarding incidents including referring to the local authority and CQC.” from the report
Cleanliness
The home and equipment were clean and hygienic, and staff followed infection prevention procedures.
“We observed the home and equipment to be kept in a clean and hygienic state.” from the report
Mental capacity
The home was following the legal framework for capacity and deprivation of liberty decisions, with appropriate applications and oversight.
“People's capacity was assessed, and the principals of the MCA followed in supporting them to make decisions relating to their care and support.” from the report
Out-of-date care plans
seriousCare plans did not always reflect people's latest needs, risks or changes after falls, skin damage or emotional reactions. Reviews did not consistently show whether care was working.
“Care plans were not always updated with risk prevention measures following incidents including emotional reactions, falls and skin damage.” from the report
Inconsistent dementia care
seriousSome people living with dementia did not receive support that reflected their individual history, preferences and emotional needs. Staff sometimes responded to distress with instructions rather than trying to understand the cause.
“People's needs were not always fully assessed or met, and care was not always person-centred.” from the report
Weak management checks
seriousCare records, recruitment records, daily care entries and records of concerns were not always complete or accurate. Inspectors said the systems for checking and improving quality were not robust enough.
“Records were not always present or complete and systems to assess, monitor and improve the service were not sufficiently robust.” from the report
Limited time for people
needs fixingThere were enough staff for basic care, but staff were busy and interactions were often task-based. This meant there was less time for comfort and person-centred support.
“There were enough staff to ensure people's basic care needs were met, but staff did not have the time to spend quality time with people.” from the report
Nutrition checks
needs fixingThe home's nutritional screening tool was not always used correctly. Referrals were rejected in some cases, and care plans were not always updated after weight loss.
“We saw instances where referrals had been made to health professionals and rejected because the MUST tool had not been followed.” from the report
Staff speaking up
needs fixingSome staff did not feel able to raise issues with the registered manager, or felt that concerns were not always acted on. The provider was asked to explore these barriers.
“However, some staff told us they didn't always feel able to raise issues with the registered manager or felt issues they raised were not always acted on.” from the report
- 01How will you make sure each person's care plan is updated after falls, skin damage, emotional reactions or other changes in need?
- 02What specific dementia care training and supervision are staff receiving, and how will you check that it improves responses to distress?
- 03What changes are being made to staffing levels so staff have time for comfort, conversation and person-centred care?
- 04How are you making sure nutritional screening is completed correctly and that weight loss leads to updated care plans?
- 05How can staff raise concerns confidentially, and how will you show that concerns are recorded, investigated and acted on?
This was an unannounced focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not rated, and the Effective rating remained Requires Improvement from the previous inspection. This explanation was written from the published report of 14 March 2024 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, November 2022
Rated Good overall; inspectors found kind, safe care, but the service was not always effective and needs to improve some records and the dementia environment.
The unannounced inspection took place on 22 September 2022. Inspectors spoke with people, relatives and staff, observed care, toured the home and checked care, medicines, staffing and management records. They also reviewed infection prevention and control arrangements.
The home was rated Good overall, and was rated Good for Safe, Caring, Responsive and Well-led. People said they felt safe and praised staff for being kind, respectful and supportive of their independence. Medicines, risk assessments, recruitment and quality monitoring had improved.
Effective was rated Requires Improvement, as some best-interest and Deprivation of Liberty Safeguards records needed improvement, health passports had not been completed, and the dementia area was not sufficiently dementia-friendly. Staff deployment at mealtimes was also not always suitable. The home had improved from Requires Improvement at the previous inspection and was no longer breaching regulations.
Safe medicines
Medicines were stored safely, staff were trained and competent, and regular audits helped identify and address problems.
“People received their medicines as prescribed, and medicines were administered by staff who were trained and competent to do so.” from the report
Kind and respectful care
People were treated with kindness and their wishes were respected. Staff also supported privacy, dignity and independence.
“Observations showed staff treated people with kindness and respected their wishes.” from the report
Personalised support
Care plans included information about what mattered to people and the support they needed, while encouraging independence.
“Care plans contained person-centred information that focused on what was important to the person and provided details as to the level of support they required, whilst promoting independence.” from the report
Improved management
The home had introduced regular quality checks and action plans. It had improved enough to end the previous breach of governance requirements.
“Effective governance systems were now in place and completed on a regular basis.” from the report
Safeguards and best-interest records
needs fixingSome best-interest records had gaps, and some applications to renew Deprivation of Liberty Safeguards were late. The manager knew about these issues and was taking action.
“We identified some gaps in best interest record and examples where DoLS applications had not been renewed in a timely manner.” from the report
Missing health passports
needs fixingHealth passports had not been completed. This could delay the sharing of important information if someone needed to go to hospital.
“Health passports, which contain essential information should a person require hospital admission, had not been completed.” from the report
Dementia environment
needs fixingAlthough the home had been refurbished and was clean, the dementia area had not been designed sufficiently around the needs of people living with dementia.
“However, minimal consideration had been given to the design and décor of the dementia unit to ensure it was 'dementia friendly'.” from the report
Mealtime staffing
needs fixingInspectors saw that staff were not always deployed appropriately at mealtimes to meet people's support needs. The manager agreed to monitor this.
“We observed the deployment of staff at mealtimes was not always appropriate to meet people's support needs.” from the report
- 01Have health passports now been completed for every person, and how are they kept up to date?
- 02How do you make sure Deprivation of Liberty Safeguards applications are renewed before they expire?
- 03What changes have been made to make the dementia unit more dementia-friendly?
- 04How do you check that enough staff are in the right places to support people during meals?
- 05What activities and social opportunities are available for someone with my relative's interests and needs?
This was an unannounced inspection covering all five key questions and infection prevention and control; the previous overall rating was Requires Improvement and had changed to Good at this inspection. This explanation was written from the published report of 2 November 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 Boroughbridge Manor and Lodge Care Home
7 rated inspections over 9 years: the service has held its Requires improvement rating throughout.
- March 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
Read what inspectors found at Boroughbridge Manor and Lodge Care Home →
- November 2022Goodup from Requires improvementSafe: GoodEffective: Requires improvementWell-led: Good
Read what inspectors found at Boroughbridge Manor and Lodge Care Home →
- June 2021Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- June 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- April 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2015Requires improvementSafe: InadequateEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Report published without a new overall rating.
- July 2013
Report published without a new overall rating.
- December 2012
Report published without a new overall rating.
- August 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 28 November 2011.
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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