Archived: Bywater Hall and Lodge

The inspection took place on 1 December 2015 and was unannounced. At our last inspection in December 2014 we found the provider was in breach of two regulations and asked them to take action to make improvements Bywater Hall provides accommodation and personal care for up to 44 people who may be living with dementia or other mental health conditions. The home is set in its own gardens. There are two floors, each with its own living and dining rooms together with en-suite, single bedrooms. There is a lift connecting the two floors.

The home did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission 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. There was a recently recruited manager in post who had submitted an application to register with the CQC.

At our previous inspection we found the provider was in breach of Regulation 13 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Management of Medicines. Under the new regulations this equates to Regulation 12 Safe Care and Treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in December 2015 we found evidence the provider had taken action and was meeting the requirements of the regulation. Staff received training in the safe administration of medicines and we saw these were stored and managed appropriately. People told us they received their medicines on time. We found one error in the stock count of a controlled medicine and the provider told us they would take action to prevent recurrence of the error.

At our previous inspection we also found the provider in breach of Regulation 22 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, Staffing. This equates to Regulation 18 Staffing of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At our inspection in December 2015 we found evidence to demonstrate the provider had taken action and was meeting the requirements of this regulation. Staffing levels were appropriate to people’s care and support needs safely, and people told us there were enough staff. We saw evidence of use of bank staff to ensure gaps on the rota were covered and saw the provider was in the process of recruiting new staff.

We looked at all areas of the home and concluded there were sufficient domestic staff to ensure the environment was safe. There were some malodours present in seating in a communal area and the manager told us they had a plan in place to rectify this.

Risk to people was well assessed and used to develop individual care plans. Although care plans contained sufficient information we found them bulky which meant it was not always easy to find the information we were looking for. We fed this back to the provider’s operations manager during the inspection.

Policies and procedures were in place to ensure people who used the service were protected from abuse. Staff received training in the safeguarding of vulnerable adults and knew how and when to report any concerns. In addition we found the provider managed accidents and incidents well, making appropriate healthcare referrals where needed. Systems for reporting incidents to the local safeguarding authority and the CQC were robust and well managed.

Staff training was comprehensive and kept up to date, meaning they had the necessary skills to provide care and support to people. Staff told us they felt well supported, although we found that supervisions and appraisals had not been kept up to date. The manager was aware of this and had already taken steps to improve this.

We saw evidence people’s health needs were supported with access to other healthcare professionals as required. A visiting health professional told us they felt the staff were responding well to their input and they had seen improvement in this since the new manager had taken post.

We found the principles of the Mental Capacity Act 2005 were generally adhered to. Staff had received appropriate training and capacity assessments had been completed for people who used the service. However, we found an inconsistent approach to the recording of consents in people’s care plans. The manager had identified this as an area for improvement before our inspection.

People told us the service was caring and we saw evidence of good practice regarding people’s dignity and privacy throughout the inspection. Staff were able to tell us about the care and support needs of people who used the service. People told us they were cared for by staff who understood those needs. We found people’s care plans contained up to date information which showed how people’s care needs would be met, although there was an inconsistent approach to evidencing people’s involvement in defining or reviewing care needs.

We saw evidence of a programme of activities in the home and were told how this was developing with input from people who used the service.

The provider had robust policies and procedures in place to ensure complaints were recorded and resolved. A clear course of action was set out and we saw the provider actively involved people who had raised concerns or complaints at all stages in the process.

Staff and people who used the service were very positive in their feedback about the manager. They told us the manager was approachable, supportive and caring. We saw evidence of good leadership driving improvements in the service.

People were consulted in the running of the home and given opportunity to provide feedback. The manager and provider were working together to improve the effectiveness of quality monitoring and audit in the home.