We carried out a review of the data available to us about Bourne Wood Manor Care Home on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Bourne Wood Manor Care Home, you can give feedback on this service.
Bourne Wood Manor Care Home is a care home registered to provide personal and nursing care for up to 64 people. The service provides support to people requiring care and people living with dementia. At the time of the inspection, there were 59 people living at the service, some of whom were living with dementia.
People’s experience of using this service and what we found
People and their relatives told us staff were kind and caring towards them and they felt safe living at Bourne Wood Manor Care Home.
Staff were aware of risks related to people’s care and how to support people appropriately. Staff knew how to whistleblow and raise concerns inside and outside of the organisation should they need to.
There were sufficient staff deployed to support people with their needs.
There were plans in place in the event of an emergency evacuation. Staff had completed individual personal emergency evacuation plans for people.
We were assured the service were following safe infection prevention and control procedures to keep people safe.
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.
People, their relatives and staff told us they were given the opportunity to feed back on the service and attend meetings. Where the provider had identified areas of improvement in relation to people being able to access external healthcare professionals, the provider had plans in place to address this.
People, their relatives and staff told us there was generally a positive atmosphere at the service which engaged them. They told us that the service was managed effectively and generally spoke positively of the management of the service.
There were systems in place to monitor the quality of the service and make improvements where shortfalls were identified.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 24 November 2021).
Why we inspected
The inspection was prompted in part by concerns received about staff management of people’s risks following falls, strokes and other deteriorations, and the culture in the service. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. We did not find evidence of the concerns we received prior to the inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bourne Wood Manor Care Home on our website at www.cqc.org.uk.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
Bourne Wood Manor is a care home providing personal and nursing care to 47 people aged 65 and over who may be living with dementia, have sensory impairment, or general frailty. The service can support up to 64 people. The home is bright and spacious and provides accommodation over two floors. Communal spaces include a bistro area, a hair salon, a family dining room, and a cinema room. Many of the rooms have direct access to the garden.
People’s experience of using this service and what we found
Staffing levels in the home were adequate despite recent recruitment challenges. On the day of inspection we observed that the way the staff were organised did not provide many opportunities for engaging with people.
Staff were recruited safely and appropriate checks made to ensure that people had the right values and experience for the role. When the provider used staff from an agency, appropriate checks were made and they were given an induction which included being shown around and meeting the people that they would be supporting.
People and relatives that we spoke with told us they were happy with the care provided at Bourne Wood Manor and felt safe. We received a lot of positive feedback about the new registered manager from relatives and staff, although some people felt communication from the service could be improved upon.
People’s risks were understood and well managed, with a focus on positive risk taking. Medicines were well managed and infection control procedures were robust and effective.
The new registered manager was very passionate about her role and the home. They had a clear vision and many ideas for improvement to enhance people’s lived experience at Bourne Wood Manor. They understood their responsibilities and engaged well with other organisations, healthcare partners and the regulator.
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.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 1 February 2019).
Why we inspected
We received concerns in relation to staffing levels at the home. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.
We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report.
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.
The overall rating for the service has remained the same. 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 Bourne Wood Manor on our website at www.cqc.org.uk.
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.
People were supported to host visitors as per the national guidance. The management team reviewed the home environment and layout and made a range of changes to enable safe visiting. For example, there was a designated visiting room which was disinfected between visits and well-ventilated. Visitors were screened for COVID-19, tested and supported to perform hand hygiene and put on personal protective equipment (PPE) prior to staff escorting them directly to the visiting room via the home garden. People were also supported to use technology to communicate with their loved ones throughout the pandemic.
People were supported to go out of the service for socially distanced car trips with staff in a COVID-19 secure way. Where people’s mental health was affected by COVID-19, the provider risk assessed and implemented additional measures to enable people to participate in activities which improved their wellbeing and protected them from infection.
The management team analysed infection outbreaks in the service and considered any potential long-term impact on people. People were supported to minimise potential risk such as falls or hydration and nutrition. Staff assessed people’s changing needs following a COVID-19 infection and addressed those in staff training and individual care plans. For example, hydration jelly drops were trialled in the service to support people’s recovery and monitor when they regained sense of smell and taste. The service worked closely with the GP surgery on addressing any changes in people’s health needs and managing infection outbreaks.
Staff told us they received training and guidance on how to use PPE appropriately and how to adhere to good infection prevention and control (IPC) practice. The provider allocated one member of staff to act as an IPC trainer and to support the management in monitoring staff’s day to day practice. For example, the IPC trainer undertook early morning checks of staff practice and addressed issues identified around changing uniforms. Staff were able to show us how they accessed PPE in people’s rooms and explained how they went about putting on and taking off PPE and hand hygiene before and after supporting a person in close contact.
The home was clean and hygienic. The provider reviewed and updated their infection prevention and control (IPC) policy and increased the frequency of cleaning to ensure thorough and regular disinfection of premises and safe management of laundry.
This inspection site visit took place on 12 December 2018 and was unannounced. This was the first inspection since the service was registered in December 2017.
There was a registered manager in post at the time of the inspection. 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.
People told us that there were enough staff to support them safely at the service. There were sufficient levels of staff to provide support to people when needed. There were robust recruitment procedures in place to ensure that only suitable staff were employed. People told us that they felt safe living at the service and received medicines when needed. The management of medicines was being undertaken safely and they were disposed of securely.
Staff understood and managed known risks associated with people’s care. Clinical risks were monitored by nursing staff. Accidents and incidents were recorded and actions were taken to reduce further occurrence. The registered manager reviewed all accidents and incidents to ensure that patterns were identified and actions taken. Staff understood how to protect people from the risk of infection. This was a purpose-built service which was clean and well maintained. Staff understood safeguarding procedures and what action to take if they suspected any type of abuse.
Staff were sufficiently trained and supervised to ensure that they were competent to complete their duties appropriately. Staff understood the principles of the Mental Capacity Act 2005 (2005). People’s consent was sought before care was delivered. Appropriate applications were submitted to the Local Authority where people may have been deprived of their liberty. Where people were nutritionally at risk, staff monitored and took actions to address this. People told us the food was good and had access to drinks regularly. Detailed pre-admission assessments were undertaken before people moved into the service. People had access to health care professionals where needed. Staff worked well together within the service and followed guidance from health care professionals.
People were cared for by kind and attentive staff who had a positive relationship with them. Staff created a calm and relaxed atmosphere in the home and we saw that they spoke with people in a respectful yet warm and friendly manner. People’s independence and dignity was valued and protected. Relatives were welcomed into the home.
People had access to appropriate and regular activities which people told us they enjoyed. Care plans contained detailed guidance for staff on how to deliver care. Staff read and understood the care plans. Complaints would be recorded and responded to appropriately when received.
There was a comprehensive system of auditing to review the care being delivered. Actions were taken to ensure any shortfalls were addressed. People, relatives and staff felt that the service was managed well. Staff felt supported and valued and enjoyed working at the service. People and staff were asked for feedback on care and their views were taken on board. Staff worked with organisations outside of the service to support the care being provided.
Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had informed the CQC of significant events including incidents and safeguarding concerns.