Archived: Bafford House

Updated 29 April 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.

This was a targeted inspection to check on specific concerns related to COVID-19 staff testing. As part of this inspection we looked at the infection prevention and control 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

Two inspectors completed this inspection.

Service and service type

Bafford 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.

There was not a registered manager in position. When in post this means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. The partnership which the service is currently registered in has dissolved and the provider is taking action to adjust their registration.

Notice of inspection

This inspection was announced. We gave the provider one weeks’ notice. This was to give the provider time to work with infection prevention and control (IPC) specialists to make urgent improvements to their COVID-19 IPC arrangements.

What we did before the inspection

We reviewed the information of concern which had been shared with us by the local health protection team in relation to COVID-19 staff testing. We sought feedback from the local authority and local infection, prevention and control (IPC) professionals, who had worked with the service to review and improve their COVID-19 arrangements. We reviewed two infection control audits and a visiting policy and procedures which the provider had forwarded to us on request. We used all of this information to plan our inspection. 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.

During the inspection

We spoke with a representative of the provider, the deputy manager, three care assistants, two members of the housekeeping team; one cleaner and one laundry assistant. We spoke with one agency member of staff. We spoke with one person who lived in the home.

We reviewed records related to staff COVID-19 testing, staff rosters, fire drills, weekly fire alarm testing and contractor service records related to the fire alarm and emergency lighting system. We toured the building and ran the hot water at a selection of hot water outlets to see how hot the water was running.

After the inspection

We continued to seek clarification from the provider to validate evidence found and to receive confirmation on the actions they were taking since the inspection. We continued to liaise with professionals from the local authority and IPC specialists.

Updated 29 April 2021

About the service:

Bafford House is a residential care home which provides personal care to 19 older people and people living with dementia or a mental health condition. At the time of the inspection 15 people were receiving care.

Bafford House is located in Charlton Kings, a suburb of Cheltenham. The home is set in well presented gardens which people could access. There was a range of communal areas that people and their relatives could use.

People’s experience of using this service:

• People and their relatives felt Bafford House was a safe and homely place. People enjoyed spending time with the staff and were comfortable in their company.

• Staff understood the risks to people and the support they required to ensure their health and wellbeing.

• The registered manager and provider had clear plans to increase the stimulation and support people living with dementia received. The provider had provided additional support to the service to achieve this goal.

• People’s dignity and rights were protected. People were supported by caring and compassionate staff.

• Care staff spoke positively about the service and felt they were supported and had access to all the training and professional development they required.

• The provider had a clear plan and vision for Bafford House. Staff were aware of this vision and were focused on providing high quality, person centred care.

• People’s needs were met by sufficient numbers of staff to ensure people’s safety and well-being.

• Staff had a good understanding of people’s needs. People’s healthcare and wellbeing needs were being met. People were supported with their dietary needs.

• Staff understood their responsibility to report concerns and poor practices. The provider followed the duty of candour and ensured people and their relatives, as well as appropriate agencies were informed of any concerns.

• The provider had systems to monitor and improve the quality of service they provided at Bafford House. The provider ensured opportunities were taken to learn from incidents, accidents and complaints.

Rating at last inspection:

Requires Improvement (The last report was published 31 May 2018). We had not identified any breaches of the regulations, however improvements which had been made had not been fully embedded at this inspection. Following our last inspection, conditions imposed on the providers registration remained in place, which meant the provider supplied us with bi- monthly updates on their governance systems. Additionally, we met with the provider to discuss the improvements they were making at Bafford House.

Why we inspected:

This was a planned inspection based on the previous rating. At this inspection we found that the service had improved. We rated the service as “Good”. Previous CQC ratings and the time since the last inspection were also taken into consideration.

Follow up:

We will continue to monitor this service and plan to inspect in line with our inspection schedule for those services rated as Good. We have asked the provider to apply to remove conditions imposed on their registration from August 2017 as these are not required to improve the service any more.