Bowbrook House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The provider was open and honest with sharing where things went wrong and proactive in learning where mistakes were made. One relative told us about an incident where something had gone wrong. They told us, “They were completely open about what had happened and they asked me what I wanted to do about it. They made changes to what they did and acted upon an issue and were completely open and honest.”

Staff embraced the positive culture the provider promoted. One staff member told us, “Every day is a learning day, and we learn by our mistakes.”

Staff were safety conscious and proactive in reporting mistakes such as medicines errors by colleagues so they could be addressed to ensure people’s safety. Staff understood the importance of safety concerns being identified and addressed. One staff member told us, “If someone needs to be corrected or if you have a concern for someone, you can easily say it to them. They are open to those concerns.”

Learning was shared amongst staff effectively via the electronic care system and at shift handovers, so they knew how to support people safely.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The provider worked alongside health professionals including district nurses, GP’s and therapists to ensure people received the care they needed. The provider kept detailed records of input from other professionals to ensure staff were guided on how to support people in a way which met their needs safely. When people moved between services, information was shared to ensure people’s needs could continue to be met safely.

Where people needed input from health professionals, the provider was proactive and ensured people received the support they needed quickly. One person told us, “If they think you need a doctor or nurse, they will get someone to come and see you or they'll phone the ambulance.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People told us they felt safe and relatives agreed they were safe. Staff understood their safeguarding responsibilities and knew the types of abuse, the signs to look for and the action to take if they were concerned about a person’s safety.

A safeguarding policy was in place and staff reported concerns appropriately. Whilst all staff had completed safeguarding training, some staff had not completed their refresher training within relevant time scales. The registered manager assured us this would be followed up to ensure all relevant staff were up to date with their training and they complied with best practice.

Accidents and incidents were recorded, and action was taken to reduce the risk of reoccurrence. The provider worked collaboratively with local authorities and other professionals to ensure people received the support and protection they needed.

People's capacity to make specific decisions was assessed when there were concerns about their ability to do so, and assessments were clearly documented. We saw evidence individuals were supported to make their own decisions wherever possible and the least restrictive options were considered and implemented.

People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this can be done through a procedure called the Deprivation of Liberty Safeguards (DoLS), which is part of the Mental Capacity Act 2005 (MCA). We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found the provider had applied for DoLS appropriately and had processes in place to follow up with the local authority when authorisations had not been made in a timely manner.

Where recent legislative changes had been made to the DoLS, this had been shared in a timely manner, and the registered manager had attended training to ensure they fully understood the implications in terms of care deliveryand the impact on people’s rights.

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Risk assessments were generally in place to guide staff how to manage risk to people. Where we identified some gaps in risk assessments related to people’s clinical risks and behavioural risks, the registered manager addressed this immediately to ensure staff had clear guidance in place to manage risk to people. Despite the initial gaps in some risk assessment documentation, staff knew people well and understood how to manage risk to people, so this had not impacted their safety.

Staff encouraged people to take positive risks where appropriate, such as when engaging in activities of their choice and accessing the community.

People at risk of falls had bed sensors in place which they had consented to which alerted staff when they got out of bed so staff could respond quickly and help keep them safe.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Environmental checks were completed to ensure the home remained a safe environment for people to live. Checks had not always been completed in relevant timescales, but plans were in place to complete them to ensure equipment was safe for people to use. For example, checks of Portable Appliance Testing (PAT) which were slightly overdue were completed following our site visit.

Electrical safety certificates and gas certificates were in date, and the provider assured us any actions identified had been addressed.

Where the fire service had undertaken an inspection, the provider had acted quickly to address actions which had been identified to ensure the environment was safe. Fire drills were undertaken and weekly audits of fire systems were also completed.

Personal Emergency Evacuation Procedures (PEEP’s) were in place to guide staff how to support people to evacuate the building in the event of an emergency.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

People were supported by a sufficient number of staff to meet their needs safely. Staff were present in communal areas and people received care at the time they needed it without having to wait. One person told us, “There are plenty of staff to look after me, I feel safe.”

People and relatives told us they thought staff were skilled and well trained. One relative told us, “Staff are knowledgeable and well trained.” We found some staff training was out of date, but the provider assured us training had been booked to ensure compliance.

Staff were recruited safely. Staff were required to have a satisfactory DBS check and references in place before commencing their employment. Where staff were recruited from overseas, the provider undertook additional checks to ensure staff had adequate English language skills to meet people’s needs safely.

Staff had regular supervision which they told us was beneficial. This enabled them to discuss work performance, training and development needs, receive updates regarding people they supported and processes in the home.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People and relatives told us the home was always clean. One relative told us, “[My relative’s] room is spotless and always smells very clean.” We observed cleaning being undertaken during the site visit and people’s bedrooms and communal areas were clean and uncluttered.

People were supported by staff who wore Personal Protective Equipment (PPE) in line with current guidance.

Infection prevention and control audits were undertaken to check the risk of infection was being managed safely. A clear policy was in place regarding undertaking the audits which followed best practice guidance.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

People told us their medicines were administered safely. One person told us, “The nurse comes and gives me the tablets, she always gives the tablets I need.”

Medicines were stored safely in a locked medicines trolley in a locked room. Stock medicine checks we undertook showed this to be accurate.

Controlled drugs were stored and administered safely. Staff were required to double witness the administration of controlled drugs and both staff signed to confirm they had done this in a controlled drugs book.

Staff recorded medicine administration on electronic Medicine Administration Records (MAR). The electronic system prevented staff from recording medicine administration unless the required time between doses had passed. This ensured people received medicines at the time they needed them and in accordance with their prescription.

Where medicines were prescribed on a ‘when required’ basis, this was clearly documented on people’s MAR chart. Whilst staff knew when to administer these medicines to people, protocols were not always in place to guide staff when to administer ‘when required’ medicines. The registered manager addressed this immediately and sent us a protocol to evidence this had been completed.

Staff were required to undergo medicines competency checks. Where medicines errors occurred, competency checks were repeated until the registered manager was confident staff were competent.

Medicine administration audits were undertaken to ensure medicines were stored and administered safely. Missed medicines and low stock reports were received weekly which the registered manager then investigated and addressed to ensure people received their medicines as prescribed