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Archived: Bispham Gardens Good

The provider of this service changed - see new profile

Inspection Summary

Overall summary & rating


Updated 19 September 2018

This inspection visit took place on 03 and 06 September 2018 and was unannounced on the first day.

Bispham gardens is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Bispham Gardens Nursing Home is registered to provide accommodation for persons who require nursing or personal care and treatment of disease, disorder or injury for up to 28 people. Accommodation is on the ground floor. There are several communal areas including a quiet lounge, conservatory and dining area. At the time of our inspection visit there were 23 people who lived at the home.

There was a registered manager in place. 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.

At the last inspection in December 2017, we found four breaches of regulation. We found breaches in the regulations related to Safe care and treatment, good governance, safeguarding and person-centred care. We issued requirement notices for these breaches in regulation. In addition to the requirement notices we made recommendations related to dignity, consent, decision making, staff deployment, management of complaints and supervision

Following the inspection in December 2017 we asked the registered provider to act to make improvements in the areas we had noted. The registered provider was required to send the CQC an action plan, outlining how they intended to make improvements. We used this inspection process carried out in September 2018 to check the action plan had been followed and improvements made.

At this inspection, we looked at the storage, administration and documentation around medicines and found these followed best practice guidance. However, we noted best practice was not consistently followed around medicine administration. The registered manager told us this would be addressed using supervision and retraining.

The service had systems to record safeguarding concerns, accidents and incidents and acted as required to make improvements and minimise future risks. The service monitored and analysed such events to learn from them and improve the service. Staff had received safeguarding training and understood their responsibilities to report unsafe care or abusive practices. The registered provider had reported incidents to the Care Quality Commission when required.

The registered manager had robust systems to ensure people’s care, treatment and support was delivered in accordance with best practice guidance and current legislation. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Policies and systems in the service supported this practice.

Care plans held information that guided staff on people’s likes dislikes and health conditions. People told us they had access to healthcare professionals and their healthcare needs were met. Documentation we viewed showed people were supported to access further healthcare advice if this was appropriate.

Risk assessments had been developed to minimise the potential risk of harm to people during the delivery of their care.

Staff deployment was organised with staff being allocated daily tasks. However, there was mixed feedback on staffing levels.

We observed positive interactions between staff and people at Bispham Gardens. Staff used humour and appropriate touch and treated people with respect and patience.

Staff we spoke with told us they felt supported by the management team and were encouraged with their personal development.

Staff we spoke with confirmed they did not com

Inspection areas



Updated 19 September 2018

The service was safe.

Staff understood how to keep people safe from abuse.

People who lived at the home and their relatives told us people were safe. Recruitment procedures were in place to assess the suitability of staff.

Risks to people were considered and care plans developed to maximise their independence taking the risks into account.

Medicines were stored, and recorded safely.

The home was clean and well maintained. We observed staff use personal protective equipment to protect people from infection.



Updated 19 September 2018

The service was effective.

The registered provider assessed people's care needs and delivered effective care and support in line with good practice guidelines.

Care staff had the training they needed to support people effectively.

People ate a balanced diet, had enough to eat and drink and could access the healthcare services they needed.

The registered provider obtained people's consent to the care and support they received when appropriate and did not restrict people unlawfully.



Updated 19 September 2018

The service was caring.

We saw staff were kind to people and people we spoke with confirmed this was the case. Staff respected people�s privacy and dignity. We observed staff knocking on people�s doors before entering and doors were closed before support was offered.

People were supported to maintain relationships with family and friends.

Care records promoted people's uniqueness, and people told us they were involved in planning and making decisions about their care.

People's end of life care wishes were discussed and documented.



Updated 19 September 2018

The service was responsive.

Care plans consistently reflected people�s current needs.

The registered manager and care staff placed people at the centre of their care.

There were a range of daily and weekly group and one to one activities for people to participate in.

The registered provider had a complaints process and complaints were dealt with in line with their policy.



Updated 19 September 2018

The service was well led.

The registered manager was qualified, experienced and committed to providing high quality care and support to people using the service.

The management team involved people, their families, care staff and health and social care professionals in reviewing and improving the service.

The registered provider had systems and processes to monitor and make improvements.