Bearwardcote Hall Residential Home

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, this key question was rated Inadequate. At this assessment, the rating has improved to requires improvement, demonstrating that the service has taken steps to strengthen safety arrangements and address previous shortfalls. Although improvements have been identified and the risk of harm has reduced in some areas, further improvements are needed to provide consistent assurance that people are always protected from avoidable harm.

This service scored 59 (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 made improvements since the last inspection and had taken action to address the concerns identified. However, some of these changes were still being embedded, and further time was needed to demonstrate they had been sustained and were consistently delivering positive outcomes for people.

Since the last inspection, the provider had implemented a range of systems and processes in response to the issues we identified. This demonstrated that lessons had been learned and that action had been taken to drive improvement. However, some key areas such as management oversight still needed to be fully embedded and sustained in practice to demonstrate consistent and continued improvement. Further work was required to ensure people's care plans included clear goals and intended outcomes, and reflected the involvement of people and, where appropriate, their relatives in care planning. Improvements were also needed to strengthen falls monitoring and medicines management. The provider had identified these areas and was taking action to address them.

The provider had strengthened several monitoring systems and improvements were evident in several areas of care delivery. However, further work was needed to ensure this was consistently completed and documented, so that leaders could be assured people's safety and wellbeing were being effectively monitored.

Whilst improvements had been made to monitoring systems, particularly in relation to people’s fluid intake, nutrition and repositioning needs, further improvement was required in the monitoring of people following a fall. Staff were able to describe the observations and checks they undertook after a fall, however, records did not evidence that these had been completed. This meant the provider could not be assured that post-fall monitoring was always carried out in line with people's assessed needs and the provider's procedures.

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 and their relatives told us they felt safer using the service and described improvements which had increased their confidence in the care provided. They said staffing levels had improved, meaning support was available when needed, and changes to the environment and furniture helped create a safer and more comfortable place to live.

We found that the provider had strengthened their systems and processes, and effective measures were now in place to ensure accidents and incidents were properly investigated and analysed. The registered manager had taken appropriate action when safeguarding concerns arose, including fulfilling their duty of candour and reporting matters to external agencies such as the local safeguarding team. Staff told us they had seen positive changes within the service and were confident in raising and escalating concerns both internally and externally if needed. Staff were also up to date with safeguarding training, ensuring they had the knowledge and skills to recognise and respond to potential abuse or harm.

The provider had made improvements in the assessment and management of risks to people's health, safety and wellbeing. However, further work was needed to ensure care planning was fully person-centred and reflected people's preferences, goals, and desired outcomes.

The provider had made some improvements since the last inspection. Risks to people's health, safety and wellbeing were identified and managed more effectively, and staff had access to improved guidance and training to support people safely. Risk assessments were reviewed and updated when people's needs changed. However, records did not consistently demonstrate that people and their relatives were involved in developing and reviewing care plans. In addition, care plans did not always include personalised goals or outcomes to reflect what people wanted to achieve or maintain. This limited opportunities to ensure care was planned around people's preferences, aspirations and choices. The provider recognised these areas required further development and had plans in place to strengthen care planning and increase the involvement of people and their relatives in care reviews and decision-making.

The provider had taken effective action to address many of the environmental concerns identified at the previous inspection, resulting in a safer and better-maintained environment for people. However, improvements to parts of the premises remained ongoing and further refurbishment was required to ensure the environment consistently met people's needs and promoted their safety and wellbeing.

The provider had made several improvements to the environment since our last inspection. The damp and mould issues previously identified had been addressed, windows had appropriate restrictors in place, and wardrobes had been securely fixed. We also saw that the stair bannisters had been replaced, which had improved the safety of the staircase. In addition, actions identified following Legionella risk assessments had been completed, and regular environmental checks were being carried out to help ensure the premises remained safe and well maintained. We observed that the environment was free from trip hazards, and areas of the home had been adapted to provide dedicated spaces for medicines storage and sluice cleaning.

However, further improvements were still required. While progress had been made, the first floor of the service required significant refurbishment to ensure it was safe, well maintained, and fit for purpose. At the time of our inspection, this area was not in use, and people were not being accommodated there. The provider acknowledged these concerns and told us they had plans in place to complete the necessary work. Therefore, although improvements had been made since the last inspection, further action was needed to ensure all areas of the home consistently met the required standards.

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.

Staffing arrangements had improved since our previous inspection, with the provider increasing staffing levels to help ensure people's needs could be met safely and in a timely way. Staff told us there were enough staff on duty to support people and carry out their roles effectively. The provider had also strengthened their recruitment, induction and training processes to ensure staff had the skills and knowledge required to support people safely.

The provider had continued to develop its training programme, and staff received a range of training relevant to their roles. Staff told us they felt supported and had access to guidance when needed. We saw evidence of ongoing management oversight of staff training and competency, which helped to promote safe and consistent care.

Feedback from relatives about staffing was mixed. While some relatives told us staff knew people well and provided caring support, others expressed concerns about the frequent use of agency staff and the impact this could have on continuity of care. The provider was aware of these concerns and had taken steps to increase permanent staffing levels to reduce reliance on agency workers.

The provider assessed and managed the risk of infection. Infection prevention and control arrangements had improved since our last inspection. The provider had taken action to address previous concerns and had introduced a dedicated sluice area to support the safe cleaning and decontamination of equipment. Staff had access to appropriate guidance and facilities to help manage infection risks and reduce the potential for cross-contamination.

We found the cleanliness and maintenance of the environment had improved. Areas of the home were visibly cleaner and more hygienic, and the provider had implemented regular environmental and cleaning checks to monitor standards and identify any issues promptly. Improvements had also been made to waste management processes, including the disposal of continence products, helping to promote safe infection prevention and control practices.

Laundry arrangements had also improved, with processes in place to support the separation of clean and soiled items and reduce the risk of cross-contamination. These improvements helped to provide a cleaner, safer environment for people living at the service.

The provider had made improvements to medicines management and appropriate systems were in place to support the safe administration and storage of medicines. However, medicines governance arrangements were not always fully effective, and further improvements were required.

Improvements had been made to medicines management since the last inspection, and we found appropriate systems were in place to support the safe administration and storage of medicines. However, further improvements were required to strengthen medicines governance. Fridge temperature monitoring processes needed to be more robust to ensure any concerns were promptly identified and addressed. We also found discrepancies in medicine stock checks, with the recorded stock level for one medicine not matching the quantity available. In addition, an empty tube of topical cream had not been disposed of appropriately. While these issues did not result in any evidence of harm to people, they demonstrated that medicines management systems were not always fully effective and required further strengthening to ensure medicines were managed safely and consistently.