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Bowe's Court Care Home Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 12 October 2019

About the service

Bowe’s Court Care Home provides accommodation for up to 23 people who require personal or nursing care. The service provides care to people with learning disabilities, mental health problems and physical disabilities. At the time of this inspection there were 20 people in receipt of care from the service.

People’s experience of using this service and what we found

In general staff delivered consistent and timely care to people. The electronic care system prompted staff to record generic risks but did not support staff to consider other risks, such as physical conditions, which increase the risk of sepsis.

The service had one hot-lock to cover all three units’ meals and staff staggered meal times. However, we noted some hot meals were left to stand on kitchen benches for extended periods. This was not in line with Food Standards Agency guidance. Staff did not appear to appreciate the risks associated with this practice. Not all staff who prepared meals had completed level 2 food safety and hygiene training. It is a legal requirement for staff handling and cooking food have received appropriate training. The provider could not demonstrate these staff had received the appropriate supervision and training in food hygiene.

Staff deployment led to times when there was only one member of staff to support three people who all needed additional assistance.

Medicines were not always managed safely. Issues had been identified regarding the recording and application of both pain relief patches and people’s topical medicines.

We have made two recommendations regarding pain relief patches and topical creams.

The registered manager was clearly invested in providing people with a good service at the home. However. the quality assurance systems, recruitment procedures, computer generated care records and IT equipment were not supporting them to achieve the goal of delivering an effective service.

Issues had been identified with the electronic systems staff used to record and review people’s care. The care record system did not support staff to develop fully person-centred care records, meet accessible communication standards, allow staff to produce communication records and could not be translated in to easy read. People who used the service could be inadvertently excluded from contributing to their care plan.

People we spoke with were very complimentary about the service, staff and registered manager. A relative told us, "The care is outstanding. They treat my relative as I would and are so good. We have never had any complaints."

For more details, please see the full report which is on CQC website at

Rating at last inspection

Good (report published 8 November 2017).

Why we inspected

We undertook this focused inspection because concerns had been raised about the provider’s overall operation of their services.

This report only covers our findings in relation to the Key Questions Safe and Well-led. The ratings from the previous comprehensive inspection for those Key Questions were not looked at on this occasion but were used in calculating the overall rating at this inspection. The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. 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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bowes Court on our website at

Follow up

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

Inspection areas


Requires improvement

Updated 12 October 2019

The service was not always safe.

Details are in our safe findings below.



Updated 8 November 2017

The service remained Good.



Updated 8 November 2017

The service improved to Outstanding.

Families told us they were supported to be totally involved in their relatives lives and the running of the service.

The service supported people, families and the staff team in relation to outstanding end of life care and on-going bereavement support.

People were supported to have their privacy and dignity upheld by a staff team committed to supporting this for people and their families.



Updated 8 November 2017

The service remained Good.


Requires improvement

Updated 12 October 2019

The service was not always well-led.

Details are in our well-Led findings below.