Bowerfield Court

Bowerfield Court is a nursing home providing accommodation for people who require nursing or personal care and treatment of disease, disorder or injury for up to 40 people. At the time of the inspection 35 people were using the service. The nursing home accommodates people across two floors in one building, with shared communal living and dining areas and outside space, and single person bedrooms with ensuite facilities.

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

People felt there was not always enough staff to support them when they needed assistance, although they told us generally staff were kind and caring and worked hard. Records did not easily allow oversight to ensure safe recruitment processes had been completed, or that staff had received all the relevant training needed for their role.

The new management team were working hard to address any shortfalls identified within the home. There were suitable audits which were identifying issues and required actions. However, this had not yet been embedded and there were still areas of shortfall regarding care plans and record keeping. People and staff spoke very positively about the new management team and felt that improvements were being made.

Medicines were mostly managed safely. However, some records necessary for the safe and responsive administration of medicines were not in place and we have made a recommendation about this.

The care home was clean and tidy and there were appropriate checks of equipment and throughout the building. There were systems in place to ensure staff knew people’s current needs and the new manager had oversight that these were being appropriately managed such as wound management.

People were mostly supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, records did not always reflect how people were involved in developing and reviewing aspects of their care, or that information about a person’s capacity and any restrictions was accurate and up to date.

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 05 May 2022). The service remains rated requires improvement. This service has been rated requires improvement for 2 consecutive inspections.

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 in some areas and the provider was no longer in breach of regulation 12. However, at this inspection we found the provider remained in breach of regulations 17 and regulation 18.

At our last inspection we recommended that the provider review their process for recruitment and regulatory requirements to ensure they are following suitably robust processes. At this inspection we found the processes in place did not allow for easy oversight and further work was needed in this area.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 08 March 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance and staffing at the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bowerfield Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified ongoing breaches in relation to staffing and the overall governance of the service. We have made a recommendation in relation to medicine administration records.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Bowerfield Court is a nursing home providing accommodation for persons who require nursing or personal care and treatment of disease, disorder or injury for up to 40 people. At the time of the inspection 35 people were using the service. The nursing home accommodates people across two floors in one building.

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

We found medicines were not always managed safely across the home. The home was clean and tidy and had plentiful stock of PPE, however, various infection prevention and control (IPC) practices, records and procedures were either not in place, not up to date or not being followed. The manager implemented some of these processes during and after the inspection. Recruitment practices were not always safely followed. We made a recommendation the service reviews their recruitment process. Staffing levels weren’t always safe and some people had to wait a long time for their call bells to be answered. People were safeguarded from abuse and although there were a variety of necessary risk assessments in place, some risks had not been assessed/updated. The manager told us they were working towards improving their compliance rate for training in some areas.

People were in receipt of person-centred care and their communication needs were being met. The home had an end of life policy in place, though no one was receiving this type of care at the time of the inspection. A complaints log and policy was in place, though these documents required updating. Visitors were able to book visits to see their friends and family members and the home had an activities coordinator that planned and carried out activities with people.

There were some governance concerns in the home in relation to audits and paperwork. The service did not have a registered manager in post and there were only limited recent lessons learned documents in place. We received mixed feedback about the management of the service. There had been limited meetings for staff, relatives and people and we were only able to review a few examples of feedback. The manager told us they were working to improve continuity and increase the number of meetings for people, their relatives and staff. The service had recently sent surveys out to families and were collating their responses.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (19 February 2019).

Why we inspected

The inspection was prompted in part due to concerns received about medicines, staffing and poor care. We received concerns in relation to the management of medicines, staffing and people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe, responsive and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this. 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 Bowerfield Court on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed. We have identified breaches in relation to IPC, medicines management, staffing and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

A variety of processes to promote social distancing had been implemented. These included a one-way system into and out of the home for staff and visitors, and clear signs of the maximum occupancy of small communal areas such as the staff room.

There was visible promotion of good infection prevention and control throughout the home. This included signs regarding personal protective equipment and hand hygiene, hand sanitiser was available throughout the home and on entry to the home a verbal recording prompting mask wearing, and regular temperature checks could be heard.

Staff and people living at Bowerfield Court were supported to engage in the Covid-19 testing and vaccination programme. We were told that where people lacked capacity to make decisions for themselves, mental capacity assessments were completed, and best interest decisions made, involving relevant parties.

Guidance around safely admitting people to the home was understood and being followed. Staff supported people to maintain contact with friends and family and completed regular checks with people isolating to promote mental wellness. There were processes in place to ensure clarity of dates for when a person’s period of isolation had been completed, and when future Covid-19 testing would commence.

The provider had developed an information leaflet to provide accurate information for staff and people regarding the Covid-19 vaccine. The registered manager encouraged people and staff to engage in conversations about this in order to reassure and address any questions or concerns people might have.

People’s experience of using this service:

• Improvements had been made to the service since our last inspection. Issues relating to night staffing levels and poor record keeping had been addressed

• People living in the home and staff told us they had noticed an improvement since our last inspection and were happier.

• People told us there were always staff to help them and they did not have to wait too long to receive support.

• Staff told us they felt they had more time to spend with people and felt less rushed.

• People told us they felt safe and well looked after

• Staff worked as a team and understood the importance of the contribution made by different staff members to ensure that people were well looked after.

• Improvements had been made to the management of the home with a service manager being appointed to support the registered manager who would have more time to talk to people living in the home and resolve issues.

• The home employed a mobility therapist who helped people maintain what mobility they had.

• People received support that was personal to them and staff communicated with people in formal or less formal ways according to the person’s preference.

• The registered manager had appropriate support to enable them to meet their responsibilities.

• The service met the characteristics for a rating of “good” in all the key questions we inspected. Therefore, our overall rating for the service after this inspection was “good”.

• More information is in the full report

Rating at last inspection: At the last inspection the service was rated Requires Improvement (25 May 2018)

Why we inspected: This was a planned inspection based on the rating of the service at the last inspection.

Follow up: We will continue to monitor the service through information we receive and future inspections.

The service was last inspected by the Care Quality Commission (CQC) on 15 and 16 August 2016 where we rated the service as requires improvement overall. Following the last inspection, we asked the provider to complete an action plan to show us what they would do and by when to improve the key question; is the service safe, effective, responsive and well-led to at least good.

At this inspection we found that action had been taken to address some of the findings in the requirements made at the last inspection. However, we identified a continuing breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Good governance, in relation to the recording of topical medicines.

We also found that the provider had not fully considered a recommendation we made at the last inspection in relation to staffing levels. We found the home was still not sufficiently staffed to meet the high physical needs of some people.

We identified three further breaches of the Regulations. These were in relation to records in respect of service users, staffing levels and staff supervision.

Although we saw records that showed day staff were provided with up to date supervision and support, night staff told us they had not received supervision following the reduction of night staffing levels.

Bowerfield Court is a nursing home in High Lane, Disley, Stockport. The home is a purpose built facility registered to provide accommodation and nursing care for up to 40 people including younger adults with high level physical needs. The home also supports respite placements and provides end of life care. At the time of the inspection there were 31 people living at the home.

There was a registered manager in post at the time of the inspection. 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.

Two people and a person’s relative told us they did not always feel safe living at Bowerfield Court particularly at night time. Systems in place to consult people about whether they felt safe and protected whilst living at Bowerfield Court were not fully utilised.

Call bells were not always responded to in a timely way. Staffing levels were not sufficient at the time of the inspection to meet the needs of people who were cared for and supported by the service.

Any specific requirements or risks in relation to people taking particular medicines were clearly documented in people’s care records. However governance systems to help ensure topical medicines were administered and recorded were not used effectively.

Systems were in place and used to assess, monitor and mitigate risks relating to people’s health, safety and welfare. Risk assessments were in place to minimise the potential risk of harm to people during delivery of their care.

Care records were reviewed frequently and showed people’s dietary requirements indicated the type of food people had eaten and what they had drank. However we found some care records were not consistently maintained and accurate in relation to fluid and food intake/output amounts. Also some care record entries had not been initialled to verify the entry was accurate when changes were made to some records.

A robust recruitment and selection system was in place to minimise the risk of unsuitable people being employed to work in the service. Staff confirmed that the training they received was appropriate and supported them to carry out their job roles effectively.

The registered manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Records in relation to the Mental Capacity Act 2005 and consent were complete and up to date. Any restrictions were deemed to be in people’s best interest and the least restrictive.

We observed staff interactions with people living at the home were caring, patient, and empathetic. Staff had developed a good rapport and understanding of the people who used the service and treated people with kindness and respect. People were supported to participate in general and therapeutic activities that promoted their independence, physical and mental needs.

Complaints were addressed and recorded appropriately by the management team. People who used the service and their relatives told us they knew how to make a complaint and felt able to approach any member of the staff team if they had any concerns.

Processes were in place and followed to ensure the premises and environment was safe for people to use.

The provider was displaying their CQC rating at the premises and on their website.

Bowerfield Court is a nursing home in High Lane, Cheshire. The home is a purpose built facility registered to provide accommodation and nursing care for up to forty people including younger people with high level physical needs and older people, some of whom were living with dementia. The home also supports respite placements and provides end of life care. At the time of the inspection there were 38 people living at the home.

The manager told us she had recently been subject to a fit person interview by a CQC registration inspector and was awaiting final confirmation of her registration. We noted subsequently that her registration with the CQC had been approved. A registered manager is a person who has registered with the CQC 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.

People said they felt safe living at the home and said the staff treated them well. Staff had received training with regards to safeguarding and demonstrated an understanding of potential abuse. We initially found that stairwells and fire exits were used for the storage of equipment and wheelchairs, including an electric wheelchair with it’s battery charging. By the second day of the inspection exits and stair wells had been cleared to allow safe evacuation of the building in an emergency. Windows on the upper floor did not have restrictors or devices that met with current Health and Safety Executive guidance for care homes and no risk assessments were in place. The manager told us she would immediately address this. Other checks and risk assessments on fire equipment, water systems and electrical and gas installations had been undertaken.

The home was generally clean and tidy throughout the inspections, although dining areas were not always well cleaned after meal times. The home used an electronic system to help manage medicines safely, although there were no clear systems in place to ensure people received topical medicines (creams and lotions). Topical medicines were not always dated when opened to ensure they remained in date to use and were always effective. Clinical rooms where medicines were stored were often at a temperature in excess of 25 degrees Celsius, meaning some medicines may cease to be safe or effective.

Suitable recruitment procedures and checks were in place, to ensure staff had the right skills to support people at the home. People told us there had been frequent use of agency staff in recent months and felt that staffing was not always sufficient to meet their needs. The manager and regional manager told us dependency assessments showed the home was properly staffed, although we noted the dependency tool did not specifically highlight the high physical needs of some people. We have made a recommendation to the provider regarding staffing at the home.

Most people told us they were happy with the standard and range of food and drink provided and could request alternative dishes, if they wished. Kitchen staff had knowledge of specialist dietary requirements. Soft or pureed diets were presented in a manner that supported people’s dignity.

People and relatives told us permanent staff had the right skills to look after them, although were less sure about agency staff. Staff confirmed they had access to a range of training and told us, regular supervision took place. The manager told us annual appraisals were due to be undertaken.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. The manager told us a number of DoLS applications had been made, although none had currently been granted. There was some evidence that, where necessary, decisions had been made in people’s best interests, in line with the MCA. However, some relatives had signed consent forms on behalf of people without the home being clear they had the authority to do so, through the legal granting of Power of Attorney.

People’s health and wellbeing was monitored, with regular access to general practitioners and other specialist health or social care staff. People told us they were happy with the care provided. We observed staff treated people patiently and appropriately. Staff demonstrated an understanding of people’s particular needs. People said they were treated with respect and their dignity maintained during the provision of personal care.

Care plans reflected people’s individual needs and were reviewed to reflect changes in people’s care. Daily records were not wholly person centred and tended to highlight care plan details rather than people’s personal progress or outcomes. Some activities were offered for people to participate in including; entertainers visiting the home and group events. People and staff said they would like to see more activities at the home, especially for individually focussed events. The manager said this was an area she wished to develop in the near future. People and relatives told us concerns or complaints were dealt with appropriately. Formal complaint records were maintained and showed details of action taken.

The registered manager told us she carried out regular checks on people’s care and the environment of the home. These audits and checks had not always identified some of the short falls highlighted at the inspection. Staff were positive about the manager and the changes in the service since her arrival. Some people questioned the effectiveness of her managing this home and the sister home next door. The manager told us that effective deputy arrangements were in place to support the situation. People told us there were regular meetings at which they could express their views or make suggestions to improve their care. Records were generally maintained and stored effectively, although some room based records were not always dated or detailed.

We found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to Safe care and treatment and Good governance. We have also made a recommendation to the provider in relation to staffing at the home. You can see what action we told the provider to take at the back of the full version of the report.