We carried out a review of the data available to us about OSJCT Bemerton Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about OSJCT Bemerton Lodge, you can give feedback on this service.
OSJCT Bemerton Lodge is a care home providing accommodation and personal for up to 56 older people, some of whom may have dementia. At the time of the inspection 42 people were living in the home.
People’s experience of using this service and what we found
People's individual risks were managed in a safe way and environmental risk assessments were completed appropriately however improvements were identified in how the service managed the number of admissions into the service. People were kept safe. Staff were confident in protecting people from abuse. The provider learned from previous accidents and incidents to reduce future risks. Staff were recruited in a safe way and there were enough staff deployed to meet people's needs. Arrangements were in place for the safe administration of medicines. Infection control processes were embedded into the service and staff followed government guidance in relation to infection control and prevention practices.
An auditing process was in place to monitor the quality and safety of service provision. There was organisational learning from incidents, and concerns/complaints were well managed. The majority of staff spoke positively about management. They felt well supported and they could talk to the management team at any time, feeling confident any concerns would be acted on promptly. People views were obtained in the running of the service. Relatives provided mixed feedback regarding engagement from the service. However, all were confident to raise any concerns directly with management.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection (and update)
The last rating for this service was requires improvement (published 10 September 2019) and there were two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.
Why we inspected
This inspection took place in response to concerns we received about the safety of the service and to follow up on action we told the provider to take at the last inspection. This was in relation to risk management and governance of the service. This focused inspection looked at the key questions of safe and well-led.
We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection
The overall rating for the service has changed from Requires Improvement to Good. This is based on the findings at this inspection.
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.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for OSJCT Bemerton Lodge on our website at www.cqc.org.uk.
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.
OSJCT Bemerton Lodge is a care home providing accommodation and personal care for up to 56 older people. 35 people were living in the home at the time of the inspection. Some people using the service were living with dementia.
We found the following examples of good practice.
The service had introduced measures to prevent visitors from catching and spreading infections. Visitors were screened for symptoms of COVID-19 and were provided with personal protective equipment (PPE). A visiting room had been created, which visitors accessed without going through the main parts of the home.
Staff had received training on infection prevention and control measures and how to use PPE safely. PPE stations had been placed at strategic points throughout the home, which gave staff easy access to the equipment they needed.
Additional cleaning measures had been introduced in the home. All areas of the home were clean, and records demonstrated the additional cleaning had been completed. The provider had invested in specialist equipment to help maintain hygiene in the home. This included a Luminometer, which is used to monitor cleanliness of surfaces and check that cleaning has been carried out to an acceptable standard.
COVID-19 testing was being carried out for people using the service and staff in line with the latest guidance.
The provider was promoting safety through the layout and hygiene practices of the premises. Changes had been made to the layout of the building, including creating separate zones with specific staff teams to minimise the interaction between people. A separate section of the home had been used for people when they first moved in. This enabled people to move into the home and complete a 14-day isolation period away from other people.
The provider had updated their infection prevention and control policy to reflect the COVID-19 pandemic and additional measures that had been introduced.
The provider had worked with the public health team to help manage the outbreak of COVID-19. The provider had responded to guidance about use of specific cleaning products.
OSJCT Bemerton Lodge is a care home providing accommodation and personal for up to 56 older people, some of whom may have dementia. At the time of the inspection 49 people were living in the home.
People’s experience of using this service and what we found
Some aspects of the service were not always safe and increased the risk that people may be harmed.
Risk assessments did not always contain clear information about how to manage the risks people faced. Risk management plans had not always been updated after incidents.
Thorough recruitment checks were not always completed before staff started providing care to people.
The manager had not always notified us of important incidents in the home, as they are required to.
The systems for checking how the service was operating did not always identify shortfalls. Checks had been completed but did not identify gaps in risk assessments, lack of recruitment checks or that notifications had not been submitted.
People and their relatives were complimentary about the care they received and about the quality of staff.
People were supported to make choices and have as much control and independence as possible.
People had been supported to develop care plans that were specific to them. These plans were regularly reviewed with people.
People received caring and compassionate support from kind and committed staff.
Staff respected people’s privacy and dignity.
People received support to take their medicines safely.
People’s rights to make their own decisions were respected. People were supported to choose meals they enjoyed and access the health services they needed.
The manager provided good support for staff.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection
The last rating for this service was good (published 10 January 2017).
Why we inspected
This was a planned inspection based on the previous rating.
We have found evidence that the provider needs to make improvements. Please see the safe 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.
Follow up
We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
OSJCT Bemerton Lodge Care Home is registered to provide personal care for up to 56 people. On the day of the visit, there were 54 people at the home.
There was a registered manager for the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
There were constant friendly and caring interactions between staff and people. People received care that respected privacy and dignity and promoted their independence. There was a welcoming, homely atmosphere in the home. Links with family members were promoted and encouraged. Mealtimes were sociable and made into a very enjoyable experience where people could invite guests to join them. This meant that people were helped and encouraged to maintain relationships with those who mattered to them.
The staff understood how to keep people safe and knew their responsibilities to protect people from the risk of abuse. New staff were recruited only after a through safe recruitment process.
People were cared for in a way that was kind and compassionate. Staff had built strong and caring relationships with people, their families and friends. People were treated with dignity and the greatest respect at all times. Staff treated people as individuals and respected their lifestyle choices.
The home was run in an open and inclusive way for people who lived at the home. Their views and wishes were central to how it was run. For example, their opinions were actively sought about how the home was decorated and maintained. People told us they were regularly asked by the registered manager to give their opinions of the staff and whether they felt well supported by them.
People who lived at the home were very well supported to take part in activities of their choosing. People enjoyed the activities and the opportunities made available to them. There were active links with the local community and people were encouraged to be part of their own community. The management used research and learning. This was to improve and develop the care people received and their overall quality of life.
The service was very responsive to the needs, preferences and wishes of people who lived at the home. The care provided was very person centred and met people's individual and diverse needs. People and their families, continually review people's needs. When people's needs change, they take action to ensure they provide the best care possible for the individual. The service was good at helping people to enjoy their lifestyle.
People were aware of how to complain and make their views known .The provider actively sought the views of people and their families. These views were acted upon and changes were made to the services when needed.
Feedback about the home from people and others involved in their care was very positive. Regular reviews were carried out of the care people received to see where improvements were needed and the service could be further developed. There were quality checking systems in place to monitor the service to ensure people received care that was personalised to their needs.
Staff and people who lived at the home spoke very positively about the management structure of the service. They said that the registered manager provided strong and very caring management and leadership. The staff team told us they were very well supported by the registered manager, who spoke very positively about their role. Staff and people at the home said they saw them daily and they were always there and helped them whenever they needed support and guidance.
People said they liked living in the home and received the care they needed. One person told us 'the home is quite perfect for me.' The relative of a person described the home as 'brilliant, they really know how to look after X'. We saw people who were at nutritional or pressure ulcer risk had clear assessments and care plans. These were regularly reviewed.
The home followed national guidelines on infection control. The member of staff who led in this area performed regular audits. All parts of the home we inspected were clean, this included light switches, grab rails and undersides of raised toilet seats.
People told us there were enough staff to meet their needs. One person said 'oh they're very prompt in coming when I ring my bell.' A visitor told us 'staff have always got time' for their relative.
We saw the home had a clear, auditable complaints procedure. A person told us the manager's door was 'always open'. They said any issues or questions they raised were always dealt with promptly.
People commented favourably on the food. A person told us 'the food's lovely, oh yes there's choice' and another 'we get good food here'. We saw the chef was closely in involved in serving meals, so they could gain direct feedback on what people thought about them. We observed that people who were frail received the support they needed to eat their meals.
We met with twelve members of staff, including domestic workers, care workers, the manager and an area manager. Staff said they were trained and supported in their role. One member of staff told us 'training for new staff is very good' and another 'the Trust are very good about training'. Staff also told us about regular supervision from their line manager.
The home was regularly reviewed by the provider to ensure people received a quality service. Where areas for improvement were identified, action plans were put in place. One relative described how they appreciated the 'very open door policy' from the manager. The home was clean throughout and there were effective systems to reduce risk of infection.
There was a lack of consistency in assessment of people's needs and care was not always planned and delivered in a way that met individual's needs. People were not supported to participate in recreational activities in the way they wanted or needed. The home's quality audit was detailed, however it did not document all areas which could have benefitted from action by the provider.