Bedford Care Home

People’s experience of using this service and what we found

People told us they felt safe living at Bedford Care Home. Enough staff were deployed to meet people’s needs, albeit people commented on staff being very busy and not having much time to chat with them. Staff knew how to identify and report any safeguarding concerns. Accidents and incidents had been logged consistently on the provider’s electronic system, with analysis completed to look for patterns and trends to help prevent a reoccurrence. Medicines were being managed safely, by staff who had been trained and their competency assessed. The home was clean with effective infection control processes in place.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Staff received sufficient training and support to complete their roles. People’s healthcare needs were being met. Timely referrals to the necessary professionals had been made when any issues or concerns had been noted. People told us they had enough to eat and drink each day, although comments on the quality of the food provided varied. People’s food and fluid intake was documented, as was the provision of personal and oral care, however, this process required strengthening. Some consideration had been made to ensure the environment was suitable for people who lived at the home.

We have made a recommendation about the completion of research into personalisation and dementia friendly décor.

Care files provided information about people’s needs and how they wished to be cared for. The provider had switched to an electronic care planning system and was in the process of finalising the transfer of information from the previous paper based files. People provided mixed views about the social and recreational activities available within the home, which had been affected by the loss of two activity co-ordinators and the COVID-19 pandemic. A weekly schedule was in place, with each unit having one planned activity per day throughout the week. Recruitment for additional activity staff was ongoing, to enable the frequency of activities to increase across the home. People said they knew how to complain but had not needed to.

The home used a range of systems and processes to monitor the quality and effectiveness of the service provided. Actions had been identified and added to the home’s improvement plan, which was regularly reviewed, both by the registered manager and at provider level. People and staff’s views were sought through regular meetings and questionnaires.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 18 April 2020) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 11 March 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and staff support.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective, Responsive and Well-Led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bedford Care Home on our website at www.cqc.org.uk.

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

Robust processes were in place for any visitors to the home. This included completion of a risk assessment, temperature check and lateral flow device (LFD) test.

Visiting was being facilitated in line with local and government guidance. An empty unit had been repurposed into a visiting area, with four separate rooms used, which were accessed directly from outside, to prevent unnecessary access to the wider unit or home. Relatives were asked to arrive 30 minutes prior to their visit slot, to enable testing to be completed. The home also had a separate ‘pod’ which had also been used to support safe visiting.

When in person visiting was not possible, the home had used other methods to maintain contact between people and their relatives, this included window visits; arranged through a booking system to ensure limited numbers of people were on site at one time, video calls and online meetings.

Staff training in LFD testing had been completed, to help facilitate visiting. Staff had also completed training courses in COVID-19 and personal protective equipment (PPE). Competency assessments had been completed and were refreshed, to ensure staff were donning, doffing and using PPE correctly.

The premises looked and smelled clean. The home had robust cleaning procedures in place, which had been amended in response to the pandemic. Frequent touch points had been cleaned regularly, with care staff completing this task alongside each unit’s housekeeper. Guidance relating to best practice guidance around cleaning was in place and being followed.

The home had a plentiful supply of PPE, which was worn correctly and consistently by staff. Staff travelled to work in their own clothes, changing into their uniform on arrival in a designated changing room on each unit, before donning PPE. Stocks of PPE along with donning & doffing guidance was located both at the entrance to each unit and within.

Where possible, changes had been made within the home to promote social distancing, including spacing chairs in communal areas, such as lounges and dining rooms. Isolation, cohorting and zoning had been used effectively, to manage any cases of COVID-19.

A robust testing regime was in place, which followed government guidance. Staff completed weekly PCR tests and twice weekly LFD tests. People completed monthly PCR tests, alongside specific LFD testing to support safe access to the community, for example when attending hospital appointments.

Bedford Care Home provides personal and nursing care for up to 180 people. The home is divided into six different units, each with 30 beds. Astley and Lilford is for people who require personal care and support, Croft and Kenyon for people with mainly physical nursing needs and Pennington and Beech for people with dementia care nursing needs. The home has designated beds on two of the units for intermediate care. At the time of the inspection there were 145 people living at Bedford Care Home.

People’s experience of using this service and what we found

We identified continued issues with the management of medicines, staff supervision and support. We have made recommendations relating to safe staffing levels, care planning, suitability of the environment, supplementary charts and staff, resident and relative meeting completion as each requires improvement.

People told us they felt safe living at the home. Staff had been trained in safeguarding and knew how to report any concerns. We received mixed feedback about staffing levels, with the majority of staff telling us more were needed. The home’s systems for determining staffing levels had not been used consistently. The home had addressed some of the medicine's issues from the last inspection, however, we found medicines were not always managed safely across the home.

Staff received a detailed induction and sufficient ongoing training to carry out their roles. However, support through supervision and appraisal had not been provided consistently. People received support with nutrition and hydration in line with their assessed needs. Health needs had been met through access and referrals to a range of medical professionals. Staff supported people in the least restrictive way possible. Decisions had been made in people’s best interests, although this had not always been documented.

People and relatives told us staff were kind, caring and helpful. They knew people well and how to care and support them. People were treated with dignity and respect and their independence promoted as much as possible. Surveys were used to capture people’s views about their care and any improvements they would like to see.

People received personalised care which met their needs. Care plans were detailed, although not always updated timely to reflect changes, remove outdated information or capture people and relatives involvement in care planning and reviews. Feedback about the activity programme within the home was mixed, some people enjoyed what was provided, others felt more work could be done to cater to everyone’s needs. People knew how to complain, with the procedure displayed throughout the home. Not all complaints had been addressed timely, however, the new manager had taken action to address this.

The home had been through a number of management changes in the last 12 months. The third manager in 12 months had started at the home two weeks prior to our inspection. Changes to unit managers and other senior positions in the home had also taken place, which had impacted on consistency. The home used a range of systems to monitor the quality and effectiveness of the care and support provided. Action plans had been generated to address any issues, including those we noted during the inspection.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was requires improvement (published 25 March 2019).

At our last inspection we found breaches of the regulations in relation to the management of medicines, completion of supplementary charts, staff support and supervision and quality monitoring. The provider completed an action plan after the last inspection to tell us what they would do and by when to improve.

At this inspection, the provider had not made enough improvement and was still in breach of two regulations.

Why we inspected

We carried out this inspection to follow up on action we told the provider to take at the last inspection.

Enforcement

We have found breaches in relation to medicines management and staff support at this inspection. Please see the action we have told the provider to take at the end of the full version of this report.

What happens next?

We will request an action plan from the provider that shows what they will do to improve the quality and safety of the service. We will work alongside the provider and local authority to monitor progress until we carry out our next inspection.

Bedford Care Home provides personal and nursing care for up to 180 people. The home is divided into six different units, each with 30 beds. Astley and Lilford is for people who require personal care and support, Croft and Kenyon for people with mainly physical nursing needs and Pennington and Beech for people with dementia care nursing needs. The home also has designated beds on two of the units for intermediate care. At the time of the inspection there were 153 people living at Bedford Care Home.

The current provider took over responsibility for the home in February 2018, following our last inspection.

People’s experience of using this service:

We found improvements were still required in key areas including medicines management, staff supervision and support, record keeping, involving people, relatives and staff in the running of the home and the quality monitoring process. Internal and provider level audits had picked up on the majority of issues we noted during the inspection, however action taken had either not been maintained or been implemented timely.

People and their relatives were positive about the standard of care provided and spoke highly of the staff, who were described as ‘wonderful’, ‘caring’ and respected people’s right to privacy and dignity. Whilst people and the majority of staff we spoke with felt current staffing levels were enough to meet needs, relatives and some staff disagreed. We have recommended the provider considers how staffing levels are determined.

Staff had received training in safeguarding and knew how to identify and report any concerns. Accidents, incidents and falls had been recorded consistently with action taken to prevent reoccurrence. This helped keep people safe. We found the home to be clean, odour free with effective cleaning and infection control processes in place.

People received personalised care which met their needs. Care plans explained how people wanted to be cared for. These had been reviewed regularly to reflect people’s changing needs and wishes, although people or their legal representative’s involvement in this process had not been captured consistently.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People felt the staff were well trained and knew their likes, dislikes and interests. We saw lots of examples during the inspection which demonstrated this. People spoke positively about the choice and standard of meals provided and we found people requiring a modified diet received these in line with professional guidance.

People told us staff were kind, caring and treated them with dignity. People’s independence was encouraged and promoted. We saw people had developed positive relationships with the staff, who had taken the time to get to know them. Where people required support at the end of their life, this was carried out respectfully, compassionately and with professionalism.

The home had a clear management structure in place, albeit was still recruiting to some key roles. The management team across the home were actively engaged in addressing poor performance and promoting positive change. It was evident during the inspection, the transition from the previous provider to the current one had been challenging and further work was required, for which plans had been developed.

For more details please see the full report either below or on the CQC website at www.cqc.org.uk

Rating at last inspection:

At our last inspection the home was rated as requires improvement (published 20 March 2018). The home remains requires improvement. This is the second time the home has been requires improvement. We will maintain contact with the provider until the next inspection to monitor the action they are taking to improve the rating to at least good.

Why we inspected:

This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received. As the home was rated as ‘requires improvement’ following our last inspection, we returned within 12 months to check the necessary improvements had been made.

Enforcement:

Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up:

We will continue to monitor information and intelligence we receive about the home to ensure care remains safe and of good quality. Due to there not being a change in overall rating, we will return to re-inspect in line with our inspection timescales for requires improvement services, however if any information of concern is received, we may inspect sooner.

Bedford Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Bedford Care Home is a large care home with 180 beds operated by Bupa. The home is divided into six different units, each with 30 beds. Astley and Lilford cater for people who require personal care and support, Croft and Kenyon look after people with mainly physical nursing needs and Pennington and Beech care for people with dementia care nursing needs. The home is situated in a residential part of Leigh close to the town centre. At the time of the inspection there were 160 people living at Bedford Care Home.

During the inspection we identified seven breaches in five of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to safe care and treatment; including the management of medicines, staffing, meeting nutritional and hydration needs, person centred care and good governance. You can see what actions we told the provider to take at the back of the full version of this report.

We have also made a recommendation about staffing levels and how these are determined, to ensure enough staff are deployed to safely meet people’s needs.

At the time of the inspection the home had a registered manager. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People we spoke with told us they felt safe. Relatives were also satisfied with the safety of their family members and were complimentary about the care provided. The home had detailed safeguarding policies and procedures in place, with clear instructions on how to report any safeguarding concerns to the local authority. Staff had received training in safeguarding and knew how to identify and report both safeguarding and whistleblowing concerns.

We noted issues with risk management, particularly in regards to the action taken by the home when specific risks had been identified either by professionals or internal assessments. Concerns were also identified with people’s access to and use of the nurse call system, should they need to request assistance when in their room. The home took steps to address this particular issue during the course of our inspection. We also found inconsistencies with the management of people’s weight and referrals to the dietetic service, as well as the adherence to dietetic guidelines.

We saw the home had systems in place for the safe storage and administration of medicines. Overall the completion of the medication administration record (MAR) was done consistently. Staff authorised to administer medicines had completed the necessary training and had their competency assessed. However our review of medicines management highlighted gaps in some documentation such as topical medicine charts. Self-administration documentation was not always clear and we found a lack of guidance in place for some medicines and medical devices.

On each day of inspection we found the home to be clean with appropriate infection control processes in place. We saw infection control audits were completed as per the policy and toilets and bathrooms contained appropriate hand hygiene equipment and guidance, with personal protective equipment (PPE) readily available and worn by all staff when necessary. Wash basins had been fitted in people’s bedrooms, to minimise the risk of cross contamination.

We received mixed feedback from staff, people living at the home and their relatives about staffing levels. The number of staff indicated on the home’s system for determining staffing levels, matched the number of staff deployed on each unit and tallied with the rota, however feedback from people and staff indicated these levels were not sufficient to meet needs, especially at busier times.

All staff spoken with displayed a good knowledge and understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), which is used when someone needs to be deprived of their liberty in their best interest. We found the home was working within the principles of the MCA and had followed the correct procedures when making DoLS applications. We saw evidence best interest meetings had been held where necessary, with outcomes documented within care files.

We identified issues with the documentation and monitoring of people in receipt of modified diets. Supplementary charts, such as food, fluid and positional change records had not been completed consistently. We also found the procedure for managing and providing people with thickened fluid was not consistent, with inconsistencies noted in the information and guidance available to staff across the units.

On one unit we saw a person had been provided with food contrary to Speech and Language Therapy (SaLT) guidelines. We were told this was a recording issue and not an accurate reflection of what the person had eaten.

We received positive feedback about training provision from the staff we spoke with. The home used a matrix to monitor training completion and had an action plan in place to ensure staff completed required or overdue sessions. However staff spoken with provided mixed feedback about the completion of supervision meetings. We were unable to evidence meetings had been provided in line with company policy and guidance. Where staff had completed supervision meetings, the majority had been work related supervisions focusing on an area of practice they needed to be mindful of or where issues had been noted.

The majority of people we spoke with were complimentary about the food provided. We found the meal time experience to be positive, with people being supported to eat where they chose. Staff encouraged people throughout the meal and provided support as required and as per people’s needs and wishes.

Throughout the inspection we observed positive and appropriate interactions between the staff and people who lived at the home. Staff were seen to be patient, caring and treated people with dignity and respect. People who used the service and their relatives were complimentary about the staff and the standard of care received. During conversations staff displayed a good knowledge of the people they supported, their likes and dislikes as well as the importance of promoting independence wherever possible.

We looked at 32 care files in total and 14 in detail. We saw these contained detailed information about the people who used the service and how they wished to be cared for. Each file contained a range of personalised information, along with care plans and risk assessments to help ensure people’s needs were being met and the care that they received was person centred. However although care files were detailed, we did uncover a number of inconsistencies and conflicting information. For example it was not always easy to identify each person’s current needs and ability due to the way care plans had been updated. We noted care plan reviews had been completed but had not identified the issues we found.

Observations of activity provision at the home, showed a large focus on the completion of 1:1 sessions, which meant the majority of people, especially on some of the units, had little in the way of activities and stimulation throughout the day. A lack of resources, both in terms of staffing hours to support activities and in equipment and materials, was a contributory factor to this.

A detailed review of the home’s end of life policies and procedures highlighted some concerns. We found a lack of end of life care plans and guidance for staff to follow when people were at this stage of their life. Policies and procedures available did not provide practical guidance for staff, who we identified, lacked training in this area.

The home had a range of systems and procedures in place to monitor the quality and effectiveness of the service. Audits were scheduled to be completed on a daily, weekly and monthly basis and covered a wide range of areas including medication, care files, infection control and the overall provision of care. We found completion of these audits to be inconsistent across the units. Provider level audits had also been carried out consistently. Over the last three months, these had identified similar issues to those we found during the inspection, however we were unable to evidence action had been taken to address the issues raised, as this was either not recorded or not detailed on the homes improvement plan.