Bedwardine House Residential Care Home

Updated 24 September 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

This inspection was carried out by one inspector.

Service and service type

Bedwardine 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.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. 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 three people who used the service and two relatives about their experience of the care provided. We spoke with eight members of staff including the provider, the business manager, the deputy manager, senior care workers, care workers and the chef. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

We reviewed a range of records. This included two people’s care records and multiple medication records. We also looked at a variety of records relating to the management of the service.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 24 September 2021

About the service

Bedwardine House is a care home providing accommodation and personal care for up to 25 older people. The care home is an adapted building over two floors. At the time of the inspection 13 people were living at the home.

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

Risks to people were not always identified effectively to ensure people were not at risk. Staff were not always consistent in their description of people’s needs to demonstrate safe care was always provided.

People’s medicines were not always fully managed safely to ensure they were administered or applied correctly.

Areas of improvement had taken place regarding infection control and compliance with COVID-19 requirements. However, further improvement was needed to ensure staff worn a face mask at all times.

The provider continued to have a lack of effective systems to monitor the quality of the service provided by staff to ensure people were safe. As a result, previously identified shortfalls had not always received the improvement necessary to ensure safe care and support was provided.

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 requires improvement (published 14 April 2021). The provider was in breach of one regulation. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

At this inspection enough improvement had not been made in all areas and the provider remains in breach of regulations.

Why we inspected

We received concerns in relation to aspects of the care provided and the management of the service. 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.

This inspection was carried out to follow up on a Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities).

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 as Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led relevant key question sections of this full report.

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

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

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 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 medicine management, care planning and management oversight and governance.

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.