2 February 2022
During an inspection looking at part of the service
Bournedale House is a residential care home providing personal care for up to 11 people who may be living with dementia. At the time of the inspection, nine people were living at the home.
People’s experience of using this service and what we found
We found significant concerns in relation to the infection prevention and control (IPC) practices within the service. People’s medicines were not always managed and administered safely. The provider had not adhered to safe recruitment practices. Staff told us they had not received any supervision or enough training to meet people’s individual needs. The provider did not have robust procedures and processes in place to protect people from the risk of abuse. Risk assessments had not always been completed in relation to known risks to people or plans developed for managing these risks
People’s needs and choices had not always been appropriately assessed before they moved into the home to ensure effective outcomes of their care. People were not always supported by staff who had the skills and knowledge to meet their needs. People’s individual dietary needs were not always addressed. People did not always have timely access to healthcare services and support. The physical environment had not been adapted to the needs to people living with dementia. The provider was not working in line with the principles of the Mental Capacity Act 2005.
People were not always well treated. People’s relatives expressed mixed views about how staff treated their loved ones. People’s independence was not always fully promoted. We were not assured staff had the time to listen to people and involve them in decisions.
People’s care plans were not person-centred to help staff ensure they received personalised care. They did not provide staff with clear guidance on how to meet people’s individual needs. People were not supported to follow their interests or take part in meaningful activities, and they showed signs of boredom. The provider did not have a complaints policy or systems to record or respond to complaints.
We were not assured the provider or manager understood regulatory requirements. The provider did not have effective quality assurance systems and processes in place. The provider had not established robust systems and processes to enable staff to record and report accidents or incidents. Records relating to people’s care were not always accurate. The provider had not actively sought the views of people, relatives, staff or visiting professionals on the service. We were not assured the provider or manager understood their responsibilities under the duty of candour.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This service was registered with us on 21st January 2022 and this is the first inspection.
Why we inspected
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.
The inspection was prompted in part due to concerns received about infection control and medicines management. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive and Well Led sections of this full report.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to person centred care, safe care and treatment, safeguarding people from abuse and improper treatment, receiving and acting on complaints, good governance and staffing at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.