Bishop's Cleeve Care 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 we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The provider was in breach of legal regulation in relation to people’s safe care.

This service scored 50 (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 did not always have a proactive and positive culture of safety. Leaders did not always investigate safety events. Lessons were not always learnt to continually identify and embed good practice.

Continuous improvement was not an embedded practice at the service. Staff and leaders did not cultivate a learning culture where mistakes were viewed as learning opportunities. Accidents and incidents were viewed individually and not part of a wider picture. Therefore, themes and trends were not considered when reviewing accidents and incidents, and opportunities to mitigate future risks were not considered, despite there being a high volume of falls at the service.

The provider did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different parts of the service.

For example, when one person was moved from the ground floor to the first floor, there was no investigation into a preceding accident, no care plan review, no medication review and limited discussion with relatives. This meant the provider did not always ensure there was continuity of care including when people moved between different parts of the service.

Staff did not always know what constituted a safeguarding concern. Systems were in place to record and investigate allegations of abuse and neglect; however, these were not always being utilised at the time of the assessment. Relatives gave us mixed feedback about how safe they felt the service was. We found instances of potential neglect had not been investigated as the service’s internal audits had failed to identify concerns, for example around fluid monitoring, falls and wounds.

However, we did find the manager submitted notifications to CQC and referrals to safeguarding appropriately.

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 MCA. We checked whether the service was working within the principles of the MCA and how they managed DoLS within the service. We found 4 people were under a DoLS at the time of the assessment with a further 17 people waiting for an assessment. DoLS were used appropriately and only when it was in the best interest of the person.

However, staff did not always make decisions in line with the MCA. For example, one person was supported to move from the ground floor to the first floor after an altercation with another person. The decision assumed the person would be better cared for in another part of the service which specialised in dementia. However, there were no records showing how the person was involved in decision making, and no best interest meeting was held with external professionals and relatives to ensure the decision was in the person’s best interest. This meant the person may have been moved to a different floor when other, less restrictive, measures had not been trialled and medical reasons for the incident had not been explored.

The provider did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs which was safe, supportive and enabled people to do the things which mattered to them.

Systems and processes did not effectively manage risk. While there were risk assessments in people’s care plans, these were not always accurate or completed by staff who routinely worked with the person and understood their needs. Risk assessments were not updated in a timely way following incidents, and people’s care plans contained inconsistent information about people’s risks and how staff should support them to safely manage them. For example, one person needed skilled emotional support to mitigate risk to themselves and others, however, this had not been assessed or documented in their care plan and staff did not have sufficient information to support the person appropriately. Where risk was identified, approaches were aimed at eliminating the risk, rather than supporting safe management of the risk.

The provider did not always make sure equipment, and facilities supported the delivery of safe care.

At the time of our assessment, the main lift was not operational. The service had another lift which was used as a service lift. People could use this lift; however, it was behind locked doors and people had to request staff to open the doors to allow people to use it. Relatives had not been kept up to date with regards to when the lift would be fixed or why it was broken. The provider had also not adequately assessed how people with decreased mental capacity would be able to request to go in the service lift.

The impact of environmental issues to people’s mental health were not considered by the provider. For example, the service cared for people living with dementia on the first floor, which had a balcony for people to access outside space. However, the balcony was not safe to be left open without staff nearby as the safety barriers were too low. Whilst the provider has closed the balcony for safety reasons, no consideration was given to how this would impact on people’s mental health, or ability to access the outside.

Memory boxes, dementia friendly chest of drawers and clear fronted wardrobes were in use, however these were only available to people living on the ground floor, and not in the area specifically designed for people living with dementia. After our assessment, the acting manager did ensure memory boxes were ordered for everyone who may benefit from them.

The provider did not always make sure there were enough skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care which met people’s individual needs.

Staffing levels were decided using a dependency tool however we found was not correctly completed to accurately reflect people’s needs. Staff told us at least 16 people required high levels of support; however, the dependency tool only showed 1 person as requiring high levels of support. This meant there were not enough staff to meet people’s needs. During the assessment, we observed senior staff who were administering medication were also supporting the care staff with answering call bells, covering breaks and answering the front door.

Incident reports showed errors had occurred where senior staff had been distracted, and an error subsequently occurred. Staff told us, “I don’t feel there is enough staff to meet people's needs. Recently someone called in sick and I was the only staff member on the floor for the whole shift. The senior gave some support. I was expected to care for 11 people, some of which required 2 staff to support.” People told us, “[It can be] short staffed. The call time varies. I don’t bother to use it at night because I don’t think they’d come. They have the best of intentions here, but they can’t live up to it because of the shortage of staff. There are a lot of agency staff, especially at night. They really don’t know enough. [The time I get my] evening medication varies, especially if agency staff are on.” A relative told us, “The time the carers have is very short. A lot of the carers are rushing. This has had an impact on my [relative’s] oral health where staff don’t have time to clean their teeth. More staff are needed.”

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.

There was enough PPE in the service for staff to use, and there were enough clinical waste bins in the sluice rooms. We found the service to be clean and there were no outbreaks at the time of the inspection. Chemicals were correctly stored away when not in use.

The provider did not always make sure medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

A review of medicines administration records (MAR) charts showed people received their regular medicines as prescribed. However, medicines prescribed with variable doses or on an ‘as required’ (PRN) basis were not always administered in line with prescribing instructions or in response to people’s needs.Although PRN protocols and care plans were in place, these did not always contain person-centred information, or reasons why medicines were given. We found stock counts for several people were incorrect and one person had medicine administered from the PRN stock instead of the prescribed stock, this meant the person had been placed at risk of receiving the incorrect dose of medicine. We found where people were taking anti-coagulant medicines, these were not reflected in their care plans. However, the acting manager did rectify this on the day of the assessment. Staff were not following prescribed medicine guidance by the GP for 1 person who required a 24-hour gap between doses of a specific medication, and this had been administered a second time within 24 hours.