Bishop's Cleeve 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

We identified one continued breach of the legal regulations in relation to safe care and treatment. We found the provider’s oversight had not been sufficient or effective in supporting the interim manager to address the breaches of regulations and the issues raised in the warning notices issued at our last inspection. People were being supported by a permanent staff team; however, the provider had not ensured new staff were competent in managing people’s risks. People’s care and risk management records did not always accurately reflect all decisions and recommendations taken in relation to people’s care and treatment such as people’s dietary requirements. The management and use of personal protective equipment (PPE) by staff was not in line with government recommendations. Clear systems to record the positioning and management of people’s transdermal skin patches (medicines absorbed through the skin), in line with manufacturer’s instructions, were not being completed. These concerns placed some people at risk of being exposed to harm. However, since our last inspection, we found some improvements had been made to the management of people’s care. Since being in post, the interim manager had implemented several systems to assist them in the monitoring of people’s risks and care needs. This enabled them to have an enhanced oversight of people’s known and emerging risks, including incidents and take appropriate action.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

People were supported to be aware of and involved in the management of their risks. One person told us how staff supported them with their mobility needs which included making sure a walking frame was nearby as well as a call bell to ring for assistance. They told us staff used specialised equipment to help move them safely when they were tired and less able to walk. Another person was at risk of further pressure ulcer development, and they told us how this was being prevented. This included the use of pressure reducing equipment such as a specialised mattress and by helping the person to protect their skin.

We observed one person was not fully provided with the modified food they required to reduce their risk of choking. Once this had been identified by us, action was taken by managers, to ensure this person’s food was prepared in accordance with the instructions provided by a speech and language therapist. Other people who retained food in their mouths and who were potentially at risk of choking, were helped by staff to ensure their mouths were empty at the end of eating.

Some people remained at risk as sufficient improvements had not been made to the quality and oversight of people's care records since our last inspection. This placed people at risk of being exposed to harm as staff did not have access to accurate care records which reflected people’s care and risk management plans. One person had been referred to the speech and language therapy team after they had experienced a choking incident when they had decided to eat foods which put them at risk of choking. The recommendation from the speech and language therapy team had not been accurately recorded. Conflicting information was recorded in the person’s care plan and medicines administration record, which put the person at further risk of choking. This was brought to the attention of the interim manager during the inspection and was immediately rectified. The provider's own audits identified improvements were needed in the management of people's specialised diets; however, it was not evident that this had been acted on as a priority. Systems were now in place to monitor people’s Deprivation of Liberty Safeguards expiry dates. This ensured people’s restrictions were being effectively monitored. The provider's policies were not always followed. For example, staff competencies in managing people's fluid thickeners and supporting people safely during moving and handling had not always been assessed in line with the provider’s policies. This placed people at risk of not receiving safe care and support in line with people's care needs.

Staff told us they had access to people’s care plans and risk assessments. However, the interim manager was aware that the management and monitoring of people's risks was not consistent or accurately recorded. Plans were in place to carry out a comprehensive review of each person's care needs and update their care plan accordingly. A senior member of staff had been allocated to review each person’s care plans and risk assessment. Since being in post, the interim manager had focused on recruiting and inducting a new staff team. However, staff's knowledge about the management of people's risks had not been fully assessed and staff had not been provided with sufficient training to ensure people's risks were managed safely by competent staff. The interim manager had been responsive to our feedback during this assessment and immediately addressed the training and competencies of staff to be able to safely support people’s swallowing needs.

One person told us about the equipment staff used to help move them and where it was stored. Relatives told us their family members had access to the equipment they needed to support them. This included a hoist to help a family member up off the floor when they had fallen and bath hoists.

Staff were mainly positive about the equipment at Bishops Cleeve Care Home but felt an additional mobile hoist would help them carry out their role more effectively. The interim manager stated that they would seek resources from the provider if additional equipment was assessed as needed.

Improvements had been made to the systems to monitor the safety of the home's environment such as regular health and safety meetings and maintenance audits. Since our last inspection, the interim manager had implemented regular health and safety checks including fire and legionella (bacteria found in water) checks. However, not all health and safety checks and processes were completed in line with the provider's health and safety related policies. For example, regular simulated emergency evacuations were not completed in line with the provider's fire policy.

Arrangements had been made by the provider to ensure a safe environment for people. However, we observed people’s drink thickening agents were not securely always stored to prevent health related accidents. This was immediately rectified by the interim manager. Improvements had been made to how substances hazardous to health were stored. We observed these stored in secured cupboards which could not be accessed by people using the service. We observed equipment used to move people, such as hoists, to be stored safely and away from busy thoroughfares or areas needing to be accessed by people such as toilets. People had their call bells nearby except for one person and we reported this to managers to review and address. We saw keypads in use restricting access by people to ‘staff only’ areas which could pose a risk to people, such as sluices. We observed the environment to be clutter free and tidy, reducing the risk of trip hazards. Window openings were restricted to prevent falls from a height. This meant people who lived with dementia could move around the environment, independently and safely.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We asked 3 care staff and a housekeeper to talk us through the correct donning and doffing (putting on and taking off) of personal protective equipment (PPE) when needing to enter and exit a COVID positive person’s bedroom. All staff explained how they put on PPE, which was in accordance with best practice guidance. However, their descriptions of how they took PPE off, demonstrated inconsistencies in practices, which were not in accordance with best practice guidance. We raised our concerns about the management of PPE with the interim manager who took immediate action to address this and agreed to accepting additional guidance and support from the local authority.

We observed PPE was not readily accessible and near to hand when staff needed it. There were some inconsistent use and sometimes lack of use of PPE when supporting people with their personal care needs and when preparing people’s food. For example, some staff wore gloves, some did not wear gloves and handwashing did not always take place beforehand. This was raised with the managers, who agreed to review national guidance and to seek further support on infection prevention and control.

One person told us staff always wore an apron, gloves and more recently a mask when they supported them with their personal care. Relatives told us they had been advised of the 2 different types of infectious outbreaks which had occurred in the care home. Relatives had been advised about the visiting arrangements at these times. Relatives we spoke with told us the care home was kept clean and had no mal odours. However, one relative wrote to CQC as they were not happy with the cleanliness of their relative’s room.

The provider's infection control policies reflected best infection control practices; however, staff would benefit from further guidance to support them in understanding the best infection control practices such as using and disposing of PPE. Through their own audits, the interim manager had not identified staff’s access to PPE and use of PPE was not being managed in line with current guidance. The interim manager stated they would address our concerns about the storage of PPE with the provider and revisit current best practice guidance with staff. They planned to train a staff member to become an infection control lead to help monitor the cleanliness of the home and staff practices.

We spoke with 2 people who were aware of what medicines they took. They were aware of why their medicines were prescribed, how and when they should be administered, and the risks associated with their medicines. One person confirmed they were able to discuss with staff and make their own decision about if they needed one of their medicines or not.

Staff responsible for managing and administering people’s medicines stated they had been trained to carry out this role. We spoke with 2 staff who administered medicines about the administration of people’s pain relief patches. They described how they positioned the patches which was in accordance with the manufacturer's instructions. However, there was not a consistent approach when recording where on the person’s body a patch was placed. This meant, for example, if a patch fell off and its position had not been recorded, a new patch could be placed in the same position causing potential skin irritation. Managers told us they would look at ways of providing a reminder for staff to complete this record. The interim manager stated they were aware of further improvements were needed to ensure people received their medicines as prescribed.

The provider had not ensured that people’s medicine records were accurate and reflected their prescribed medicines. For example, there were inconsistencies in the records of people’s prescribed drinks thickener which did not reflect the pharmacy label. Through their own auditing systems, the interim manager had identified that further improvements were needed to ensure the safe management and administration of people's medicines. They were making progress in implementing safe practices such as using body charts to record where medicinal dermal patches were positioned in line with manufacture's guidelines. However further time was needed to train staff and embed these practices as we found staff practices were not always consistent. The provider’s own systems to observe staff administering medicines did not include the management of transdermal patches, which meant there was a lack of oversight for managers to ensure staff were aware of the correct procedures for applying and documenting these medicines. This put people at risk of not having their medicines administered safely.