Bedford Care Home

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

People, relative’s and staff told us the home was well led and they found the current manager to be approachable. Members of the management team were a visible presence across the home and staff felt comfortable speaking up and raising any concerns. A range of audits and governance processes were used to monitor the safety and effectiveness of the care and support provided. Any required actions had been logged and outcomes recorded. The provider also used an overarching improvement plan, to log both internally identified issues and those identified by external stakeholders. Monthly meetings were held to collate and analyse any patterns and trends in accidents, incidents, falls, and other areas. These were used to support learning and drive improvements.

This service scored 75 (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 Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

At the time of assessment, the home did not have a registered manager. The current manager had applied to CQC to be registered and their application was approved the same week as our site visits. The manager had worked at the home for many years in a number of roles and as a result knew the home and staff well. Since our last inspection, the management structure at the home had changed. Each unit no longer had a manager, with a senior carer or nurse now being responsible for overseeing their respective unit. They were supported, as was the manager, by two unit coordinators. Due to the size of the home, we discussed with the provider whether additional person was needed to ensure all 6 units received enough support and oversight. The provider confirmed plans were in place to appoint a 3rd unit coordinator, specifically one with a clinical background.

The manager told us they were happy with their support network, which included a divisional director and quality and compliance staff who worked for the provider. Due to the number of changes within the home over the past 12 months, including to staffing structures, feedback from staff was mixed. However, staff reported no concerns with the current manager or how approachable and open they were.

The provider had up to date whistle-blowing policy and procedures in place, which explained how staff could raise concerns and ‘speak up’ should they identify or see any poor practice. Staff we spoke with understood their responsibilities and were able to tell us how they would raise concerns.

Staff told us management visited the units most days, which meant they were visible and accessible, should they need to raise and issues or report any concerns. The manager told us they operated an open door policy, to ensure staff could speak up, as and when required.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had a quality assurance framework in place, which clearly explained what audits, monitoring and checks would be completed and how often. Areas to be audited included, medicines, care plans, infection control practices, call bell response times, health and safety and the mealtime experience. From evidence reviewed during the assessment, we found this was being followed. Overall, the audits viewed on assessment had identified practice across the home was largely meeting expectations. Some issues had been identified, including response times to call and door bells, record keeping, including the completion of monitoring charts, and the quality of information in some care plans. For each audit completed, any actions had been logged along with outcomes. Each audit was also scored to provide a ‘compliance rating’. From looking at scores between March and June 2024, overall, we noted the compliance score had improved each time, especially where concerns had been noted, and actions taken.

To help improve record keeping and completion of monitoring charts, senior carers and nursing staff had been asked to check though all charts during shift to ensure they had been filled in as required. Provider level oversight was also completed, to ensure the home’s management was adhering to the quality assurance framework and the home was operating as expected. This included a monthly audit by the divisional director, quarterly reviews as necessary and monitoring / support visits. The provider was proactive in reporting accidents, incidents and concerns to the appropriate professional bodies in a timely manner and had submitted statutory notifications to CQC as necessary.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The provider had a service improvement plan (SIP) onto which both internally identified issues and those identified by other stakeholders, such as the local authority through their quality assurance visits, had been recorded. The SIP was separated into 2 sections, ‘in progress’ and ‘completed’ actions. At the time of our assessment, the SIP contained 224 actions, 47 of which were still ‘in progress’. From reviewing the SIP, we noted the majority of issues we noted during the assessment had already been identified with actions in place to drive improvements. These included, record keeping, care plans, décor and environment, food and fluid recording. The only exceptions to this was in relation to activity completion across the home and allocation of staffing. However, the provider discussed plans to look into these areas during discussions which formed part of the assessment process.

The home utilised a lessons learned document, which was cascaded to staff. This contained information about issues which had occurred, actions which had been taken and what lessons had been taken from the incidents to help prevent a reoccurrence. Examples included number of falls and how to reduce these and improving medicines record keeping. Each month a clinical risk and governance meeting was held to collate and analyse patterns and trends which had occurred within the home. This included the managing of behaviours, falls, incidents, wounds, nutrition, hydration and complaints. Each area included sections for recording themes and trends along with a lessons learned section. We noted some good examples of learning and subsequent actions taken to make improvements. For example, there was an increase in falls on one unit. It was identified these occurred early in the morning and at night, so the skill mix and staffing at these times was reviewed, and changes made. People’s needs were reassessed and some were identified as now requiring nursing care, so were transferred to another unit within the home. These actions had resulted in a decrease in falls.