Updated 17 January 2024
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 Health and Social Care Act 2008.
Inspection team
The inspection was carried out by 3 adult social care inspectors, a pharmacy inspector and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Bishop’s Cleeve Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. At the time of the inspection Bishop’s Cleeve Care Home was not providing nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was not a registered manager in post. The registered manager who was still registered with the CQC was no longer in post. The service was managed by an interim manager. Prior to our inspection, the provider had discussed with CQC their plans to recruit a permanent registered manager.
Notice of inspection
This inspection was unannounced.
What we did before the 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 did not complete the required Provider Information Return (PIR). This is information providers are required to send us annually with key information about the service, what it does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
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 spoke to the head of commissioning for the provider, the interim manager, the head of estates, 4 senior care assistants, 3 care assistants, the maintenance person, a laundry assistant, a housekeeper and the chef. We also spoke with 10 people and 5 relatives of the people who use the service. We gained feedback from 2 visiting professionals.
We reviewed a range of care documentation, which included 3 people’s care records in detail and various other records relating to the care of 9 other people. We reviewed medicine records. A variety of records relating to the management of the service, including policies, procedures, staff training, quality assurance and incident and accident records. We reviewed 3 staff recruitment files and records relating to staff support.