Archived: Bournedale House

Updated 12 August 2021

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

The inspection was carried out by one inspector and an assistant inspector.

Service and service type

Bournedale House 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.

The service had a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with two people who used the service about their experience of the care provided. We spoke with the provider and three members of care staff and the cook. We also spoke with a visiting healthcare professional. We observed people and staff interacting, to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included three people’s care records and multiple medication records. We looked at two staff files in relation to recruitment and staff supervision.

After the inspection

We spoke with two relatives and continued to seek clarification from the provider to validate evidence found

Updated 12 August 2021

About the service

Bournedale House is a residential care home providing personal care for up to 11 people who may be living with dementia. At the time of the inspection, 11 people were living at the home.

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

Staff were aware of the types of abuse people could be at risk of but measures in place to keep people safe from harm had not been consistently followed. There was not an effective system in place for the assessment and monitoring of risks to people. Care plans did not contain all the required information needed to guide and inform staff.

People were observed to be comfortable in the presence of the staff who supported them and people approached them for reassurance and support.

Recruitment systems were not always robust and there was no dependency tool in place to assess staffing levels. Audits had failed to identify areas for improvement in relation to medicine management. Staff had access to Personal Protective Equipment (PPE) and had received training in this area. Concerns were raised regarding the promotion of safety through hygiene practices in the home.

Staff felt supported and well trained. Where possible, 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 were supported to eat and drink and maintain a balanced diet. Referrals were made to a variety of healthcare professionals where required to ensure people’s healthcare needs were met.

People and relatives told us staff were caring. However, staff had not been provided with information regarding people’s choices in relation to their religious and cultural needs. We observed staff speak kindly to people and recognise when they were distressed and offer comfort.

Systems were not in place to support staff to communicate effectively with people. There were a lack of activities taking place that would interest people and occupy their day.

Audits in place had failed to identify a number of areas of improvement that were found on inspection. The provider was responsive to the feedback provided and demonstrated a willingness to address the concerns raised.

This service was registered with us on 2 February 2020 and this is the first inspection.

The last rating for the service under the previous provider was good, published on 25 July 2018.

Why we inspected

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 inspection was prompted in part due to concerns received about infection control, nutrition, staffing levels and staff competency levels. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive and Well Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to regulations 9, Person-centred care and Regulation 17, Good Governance at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.