Archived: Bywater Hall and Lodge

Updated 16 May 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 15 February 2017 and was unannounced. The inspection team consisted of three adult social care inspectors and two experts by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.

At the time of our inspection there were 64 people using the service. During our visit we spoke or spent time with 20 people who used the service and 12 visiting people. We spoke with nine staff, the care manager, the registered manager and area manager. We spent time looking at documents and records related to people’s care and the management of the service. We looked at seven people’s care plans and 10 people’s medication records.

Before our inspection, we reviewed all the information we held about the home, including previous inspection reports and statutory notifications. Before the inspection, providers are asked to complete a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We contacted the local authority and Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

Updated 16 May 2017

We inspected Bywater Hall Lodge on 15 February 2017. The visit was unannounced. Our last inspection took place in December 2015, where the overall rating was required improvement.

Bywater Hall Lodge provides accommodation and care for up to 88 older people. Some may be living with dementia or other mental health conditions.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

All the people we spoke with said they felt safe in the home. These were some of the comments people made, “I do feel safe, I feel there is enough staff to look after me.” “I’m happy here and feel safe.” I do feel safe here because there are a lot of people about to look after me.”

At this inspection we found some aspects of medicines management were not always in line with the provider's policy. Records did not always show when creams and lotions known as ‘topical medicines’ was applied and how often.

We received a mixed response when we asked staff about the management of the service. Some felt well supported where others did not. We saw from the staff records we looked at that supervision and appraisals had not been carried out on a regular basis, and in line with the provider’s policy. Recruitment checks had been carried out on all staff to ensure they were suitable to work in a care setting with vulnerable people.

Staff knew how to keep people safe from the risk of harm and abuse; they had received relevant

safeguarding training and knew how to report issues of concern.

We found people's health care needs were met and relevant referrals to health professionals were made when needed. People's nutritional needs were met. There were choices available on the menus and alternatives if people didn't like what was on offer.

Care plans were not signed by people or their representatives to show they agreed with the contents, and there was a lack of consent documentation for things such as administration of medicines, living at Bywater Hall Lodge and photography for medical and other purposes.

Staff we spoke with told us people could make day to day decisions about their care, for example, when to get up and where to sit. Staff said they had completed MCA training and understood that when people had capacity they had the right to make unwise decisions and when people lacked capacity, decisions had to be made in people’s best interests. One member of staff said, “I can’t make a choice for someone if they have capacity. My role is to make sure they have all the information and explain things.”

A range of activities were offered for people to participate in and people told us they enjoyed these.

There were systems in place to ensure complaints and concerns were fully investigated. The manager had dealt appropriately with any complaints received.

A range of checks and audits were undertaken to ensure people's care and the environment of the home was safe and effective. These checks had identified the issues we noted around the management of medicines but the service had not responded robustly and these were still occurring.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.