Bourley Grange

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

When incidents or accidents occurred, there was evidence the registered manager carried out investigations and implemented measures to reduce the likelihood of recurrence. Earlier this year, the service identified an increase in falls and pressure ulcers among people in their care. This was reviewed by the registered manager and clinical lead who implemented further daily checks and a review of the care pans and risk assessments of residents who were at high risk of fall or pressure sores. Following the implementation of the daily checks, there have been no further home-acquired pressure ulcers, demonstrating the effectiveness of these actions.

The service had an online system to document incidents and accidents. Staff could document actions taken, lessons learned, any areas of good practice and the outcome of any investigation completed. Where staff had recorded actions needed following an incident or accident to prevent recurrence, these were specific. For example, where a person sustained an injury resulting in bruising, staff were provided with detailed guidance to prevent a recurrence and protect the person from further harm.

The registered manager described how they maintained oversight of the service through regular monitoring and review of all incidents.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People told us they felt safe living at the service, “Safe as a rock here, no concerns at all on that front” and “All of them ever so kind, it makes me feel so safe here.” Relatives strongly agreed, “It really is a lovely home, and [person] is certainly in safe hands here.” This feedback reflected the confidence people and their families had in the care provided.

The service maintained regular communication with a range of health and social care professionals, including the local care home support team, to ensure individuals received the right care at the right time. This proactive engagement helped to identify and address health needs promptly, supporting people’s overall wellbeing.

Before anyone moved into the service, the management team carried out a pre-admission assessment. These assessments ensured the service could meet the person’s needs and support a positive transition to the service from their previous residence.

The provider demonstrated a proactive approach to safeguarding and worked collaboratively with people who use the service, their families, and healthcare partners to understand what safety meant to them and how best to achieve it. This person-centred approach ensured that safeguarding was not only about compliance but about promoting dignity, respect, and independence.

All staff had completed training in safeguarding, and this was refreshed on an annual basis. Staff were aware of the service’s safeguarding policy and procedures and where to access the policy if needed. During our assessment, staff were able to describe different types of abuse and explained how they would raise the concerns and who to. One staff member told us, “[Safeguarding is] to protect everyone requires care and support. I would report it to the manager using the whistleblowing if needed.”

Staff told us they would feel comfortable speaking to the management team about any concerns they may have. This was echoed by people and their relatives who felt confident raising concerns and trusted the management team to act on them.

Where safeguarding incidents had been identified, the registered manager had investigated the incident internally and documented actions taken. Staff were able to explain the process they would take to raise a safeguarding concern. Records showed that safeguarding concerns were escalated without delay to relevant authorities, including the local safeguarding team and the Care Quality Commission.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the Mental Capacity Act 2005 (MCA). In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, whether appropriate legal authorisations were in place when needed to deprive a person of their liberty, and whether any conditions relating to those authorisations were being met. The registered manager ensured that appropriate applications for Deprivation of Liberty Safeguards (DoLS) were made in line with the Mental Capacity Act 2005 (MCA).

The provider worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The provider had systems in place to identify, assess, and manage risks associated with people’s care and support. Risk assessments were consistent and clear and the guidance that staff should take to mitigate risks was accurately recorded. There was specific, in date, risk assessments in people’s care plans, such as for moving and handling and medicines, which staff could readily access. The service had a business contingency plan in place to meet the support needs of people in case of an emergency.

Individual emergency evacuation plans were in place and provided detailed information regarding the level of support each person would require in case of an emergency.

The provider used an online system to document all risk assessments. This enabled any changes to be made promptly. When a change had been made, this was flagged to all staff to ensure they were aware of the change in risk to the person. Staff were also able to document on the system any new risks they had identified which meant the senior care staff and management were able to update people’s care plans, accordingly, mitigating the risk.

Staff demonstrated a clear understanding of individual risks and were able to explain how they supported people to remain safe while promoting independence. For example, staff encouraged people to take positive risks, such as going on day trips, and maintaining mobility through regular movement and exercise. This approach reflected a commitment to balancing safety with autonomy and quality of life.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The registered manager ensured environmental safety was effectively managed. The service had an allocated maintenance person who oversaw the environmental safety of the service. We saw completed records of fire safety, legionella checks, and electrical checks were completed on a regular basis. Equipment used by people including wheelchairs, beds and hoisting equipment were also checked regularly. Staff also raised any issues they with the maintenance person and they were rectified as quickly as possible.

Routine safety checks were carried out and were within the safe and expected levels, such as monthly water temperatures checks on hot and cold taps, and regular flushing of unused outlets.

The service positively supported people with dementia to be as independent as possible through the environment of the service. We observed clear, well-positioned signage throughout the service to assist with orientation. For example, direction signs to communal areas were displayed at eye level and used contrasting colours, words and pictures to make them easier to understand. There were memory boxes outside people’s bedrooms which contained personal items and photographs. The service had also identified hobbies and interests that people had prior to residing at the service and supported them with this. For example, many people enjoyed gardening. The service had created both an indoor and outdoor gardening area for people and relatives to enjoy at their leisure. One person had previously worked with babies. A nursery area had been set up for the person to enjoy at their leisure.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Both staff and people felt that there were enough staff on a day to day basis to support people’s needs. Staffing numbers were also regularly reviewed by the registered manager and through a calculating system to identify the number of staff required on a monthly basis depending on people’s needs. Staff responded to people's request in a timely manner for support during the day of the inspection. We reviewed recruitment records of staff who had recently started working at the service. The registered manager used a thorough recruitment process to employ suitable staff. All staff files contained the necessary evidence including employment history and Disclosure and Barring Service checks. DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

Staff received regular supervision and annual appraisals, which were individualised and focused on their professional development and performance as well as their wellbeing.

Staff had completed all mandatory courses such as safeguarding, infection prevention and control, and moving and handling, as well as specialist training tailored to the needs of people living in the service. This ensured staff had the knowledge and skills to deliver safe, compassionate, and person-centred care.

The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

People were supported to live in a clean, hygienic environment. Staff received relevant training and knew the processes to follow to minimise the risk and spread of infection. Staff had access to resources and equipment to help them reduce infection risks such as gloves and aprons.

People and relatives told us they felt the service was clean and well maintained. Staff confirmed they had the resources and guidance needed to keep people safe from infection.

The provider made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff involved people in planning, including when changes happened.

Detailed and individualised ‘when required’ (PRN) medication guidance was in place to explain to staff when the medication is necessary. Where people received medicines with stricter controls, the medicine administration records (MAR) were signed by two staff administering the medicine as per the provider’s medicines policy. We reviewed people’s MAR and they were complete. When observing a medicines round, people were seen to be supported with taking their medicines and at the correct time. Staff responsible for administering medicines had completed competency assessments and training, which was refreshed regularly. These assessments included observed practice and knowledge checks to confirm staff understood safe administration procedures, dosage requirements, and record-keeping standards. This ensured only trained and competent staff handled medicines.

People told us they received their medicines on time and as prescribed. Observations during our visit confirmed that staff followed safe practices when preparing and administering medicines.