Archived: Bywater Lodge

Updated 29 February 2016

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.

The inspection took place on 14 December 2015 and was unannounced. The inspection team consisted of two adult social care inspectors, a specialist advisor social worker with medical and health expertise and an expert by experience with knowledge of caring for older people. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

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 did not ask the service to provide us with a PIR prior to this inspection. We contacted the local authority and Healthwatch. We were not made aware of any concerns by the local authority. Healthwatch feedback stated they had no comments or concerns. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

At the time of our inspection there were 33 people living at Bywater Lodge. During our visit we spoke with 14 people who used the service, five visitors, seven members of staff, the manager and operational manager. We spent some time looking at documents and records that related to people’s care and support and the management of the service. These included medicines records, quality checks, staff rotas, recruitment and training records, quality audits, meeting minutes and the provider’s policies and procedures.

Updated 29 February 2016

We inspected the service on 14 December 2015. The visit was unannounced. Our last inspection took place in October 2014 and at that time; we found the provider was in breach of four regulations and asked them to take action to rectify this. The provider sent us an action plan telling us what they were going to do to ensure they were meeting the regulations. On this visit we checked and found sufficient improvements had been made in these areas.

Bywater Lodge provides accommodation and care for up to 44 older people who may be living with dementia or other mental health conditions. The home is purpose built, set in its own gardens and there is parking available. The home is divided over two floors. There is a large lounge and dining room on both floors for people to use with lift access. There is also a café area. People living in the home have single en-suite rooms.

At the time of this inspection the home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The person managing the service had submitted an application to register with the CQC.

At our previous inspection we found the provider was in breach of Regulation 14 Health and Social Care Act 2008 (Regulated Activities) Regulation 2010, Meeting nutritional needs. Under the new regulations this equates to Regulation 14 Meeting nutritional and hydration needs of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in December 2015 we found evidence the provider had taken action and was meeting the requirements of the regulation. The lunch time meal experience was pleasant for people living in the home and choice and support was offered. This meant people received a suitable diet and had sufficient to eat and drink.

At our previous inspection we found the provider was in breach of Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulation 2010, Consent to care and treatment. Under the new regulations this equates to Regulation 11 Need for consent of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in December 2015 we found evidence the provider had taken action and was meeting the requirements of the regulation. The care plans we looked at showed the provider had assessed people in relation to their mental capacity. There had been Deprivation of Liberty Safeguards applications completed.

We also found the provider in breach of Regulation 22 and 23 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Staffing. This equates to Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in December 2015 we found evidence to demonstrate the provider had taken action and was meeting the requirements of this regulation. Staffing levels were appropriate to people’s care and support needs safely, and people told us there were enough staff. We saw evidence of use of bank staff to ensure gaps on the rota were covered and saw the provider was in the process of recruiting new staff. Staff told us they felt well supported, although we found that supervisions and appraisals had not been kept up to date. The manager was aware of this and had already taken steps to improve this. A programme for staff supervision and appraisal had started.

Staff training was comprehensive and kept up to date, meaning they had the necessary skills to provide care and support to people.

People’s care needs were assessed and care plans identified how care should be delivered. People and relatives we spoke with told us they were very happy with the service they received and staff were kind and caring, treated them with dignity and respected their choices.

People had regular contact with healthcare professionals; this helped ensure their needs were met.

We saw evidence of a programme of activities in the home and were told by the manager this was developing with input from people who used the service and staff.

Policies and procedures were in place to ensure people who used the service were protected from abuse. Staff received training in the safeguarding of vulnerable adults and knew how and when to report any concerns. In addition we found the provider managed accidents and incidents well, making appropriate healthcare referrals where needed. Systems for reporting incidents to the local safeguarding authority and the CQC were robust and well managed.

Staff and people who used the service were very positive in their feedback about the new management and leadership of the home. People had opportunity to comment on the quality of service and influence service delivery. Complaints were investigated and responded to appropriately.