Archived: Begbrook House Care Home

Updated 26 July 2022

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was carried out by one inspector.

Service and service type

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

Registered manager

The home did not have a manager registered with the Care Quality Commission. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided. A new manager started in post in February 2022 and they planned to register with the CQC. Throughout the report we refer to them as the manager.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

Before the inspection we reviewed the information, we had received about the home. We reviewed CQC notifications. Notifications describe events that happen in the service that the provider is legally required to tell us about.

The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report.

We used all of this information to plan our inspection.

During the inspection

We spoke with four people who lived at the home, the manager, regional director and the regional support manager. We considered all this information to help us to make a judgement about the home. We looked at a range of records relating to the management of the home, safeguarding records, quality assurance and staff recruitment.

The manager contacted, 20 staff to inform them about our inspection and gave them the opportunity to share their experience of the home by email. We received six responses in total. These comments have been referred to throughout the report.

After the inspection

We requested a range of records, including meeting minutes, information relating to safeguarding process’s and around managing good governance. We continued to seek clarification from the provider to validate evidence found.

At the end of the inspection activity we fed back to the manager, regional director and the regional support manager about our findings.

Updated 26 July 2022

Begbrook House Care Home provides personal and nursing care for up to 32 people. The service is provided in accommodation on one ground floor level. At the time of the inspection, 23 people were living at the home.

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

Although the staff we spoke with understood their responsibility to report and raise safeguarding concerns recent incidents at the service highlighted that policy and procedure were not always followed. The appropriate action had not been taken by some senior staff when they had been alerted to recent concerns. Equally staff who had raised the concerns had not escalated these to management or the local authority when their concerns had been ignored.

There were enough staff to meet people's needs. The manager used a dependency tool to calculate staffing levels. This was increased when people’s needs changed and in line with the occupancy of the home. The home followed appropriate recruitment practices and ensured staff were properly checked before they began working at the home.

People and staff felt positive about the management of the home. Effective quality assurance systems were in place to monitor the quality and safety of people’s care. Audits helped to identify any shortfalls. The manager was being supported by the regional support manager. They were temporarily based at the home. The regional director had good oversight of the home. They visited regularly and carried out checks of the home. Out of hours checks on the home took place unannounced and were carried out by senior management.

Rating at last inspection

The service was taken over by another provider and registered with us April 2020. We have not rated the service at this inspection.

Why we inspected

The inspection was prompted due to safeguarding concerns which had been reported to us by the service and the local authority safeguarding team. This was in relation to safeguarding people from abuse and the process which staff followed to report such concerns. At the time of this inspection the concerns were being investigated by the service and other agencies involved. We inspected to examine those areas of risk and to check that people were safe. This was a targeted inspection to look at key areas of the safe and well-led key question.

Follow up

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