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Bournbrook Manor Home Ltd Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 4 April 2019

About the service:

Bournbrook Manor Home is a residential care home that provides accommodation and personal care and support to a maximum of 23 older people and for some older people living with dementia. At the time of our inspection 15 people were living at the service.

People’s experience of using this service:

¿ People told us they felt safe. Safeguarding systems and practices protected people from abuse.

¿ However, people were not always kept safe because risks were not always assessed, monitored or mitigated.

¿ People shared mixed feedback in relation to staffing levels. However, staff told us there were enough staff available to meet people’s needs.

¿ Systems and practices required improving in relation to the safe management of medicines.

¿ Accidents and incidents were not always followed through with the appropriate action to minimise the risk of re-occurrence. Where lessons could be learned to improve the service, and make the care people received safer; these were not always identified and addressed.

¿ People received care from staff who had not always completed mandatory training the provider had required.

¿ Staff involved and consulted a range of health and social care professionals to ensure people's healthcare needs were met.

¿ People told us they enjoyed their meals but were not enabled or involved in the planning of their meals.

¿ Although staff knowledge of Mental Capacity Act (2005) had improved people did not always have their legal rights protected as the staff did not know which people had Deprivation of Liberty Safeguards authorisations in place or how to support people in the least restrictive way.

¿ People said staff were kind and caring but interactions between staff and people were generally task orientated with limited sustained interaction.

¿ People’s dignity, privacy and confidentiality were compromised on occasions

¿ There were limited opportunities for engagement and stimulation for people living with dementia.

¿ People did not always receive care and treatment that was responsive to their needs or provided in a person-centred way. People's care plans were not consistently being followed and some were not current or reflective of people’s needs.

¿ People were not consistently supported to be involved in the planning or reviewing of the care they received.

¿ Relevant care documents were not accessible to meet people’s individual communication needs.

¿ People told us they felt confident to raise a complaint. However, Information about how to raise concerns had not been produced in an accessible format for people who had a visual or cognitive impairment.

¿The provider had developed systems for identifying, assessing and mitigating risks, however, these had not always been operated effectively. The registered manager carried out audits of the service but these had failed to ensure that people were always safe and that their needs were being met.

¿ The providers systems had not been effective at improving the quality of the service and the service had failed to achieve and sustain a minimum overall rating of ‘Good’ at three consecutive inspections.

¿ A new management team had been introduced and they were very committed to driving improvement to enhance the quality of the care and support delivered to people.

Rating at last inspection:

The service was rated Requires Improvement overall. Our last report was published on 02 May 2017.

Why we inspected:

This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received. At this inspection on 05 March 2019, we found the provider had failed to sustain and build on improvements and the service had deteriorated.


We found that the provider was not meeting all of the requirements of the law. We found multiple breaches in regulations. You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC's regulatory response

Inspection areas


Requires improvement

Updated 4 April 2019

The service was not always safe

Details are in our Safe findings below.


Requires improvement

Updated 4 April 2019

The service was not always effective

Details are in our Effective findings below.


Requires improvement

Updated 4 April 2019

The service was not always caring

Details are in our Caring findings below.


Requires improvement

Updated 4 April 2019

The service was not always responsive

Details are in our Responsive findings below.


Requires improvement

Updated 4 April 2019

The service was not always well-led

Details are in our Well-Led findings below.