Archived: Bournedale House

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.

We found the following examples of good practice.

The provider utilised technology to meet care needs and support the delivery of care. Symptom checks, records of observations and care notes were stored as digital logs. This promoted timely and responsive care and support.

Staff were observed wearing PPE in line with Government guidance. Signs in the home prompted the staff team to maintain good infection control practices. Staff compliance with infection prevention and control procedures was monitored through a process of competency assessments and supervision which included observed practice.