CQC report explained · a residential care home
What the CQC found at Bafford House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found ongoing risks involving water temperatures, building maintenance, keypad locks and choking. Safeguarding concerns had not always been reported promptly, although medicines, falls management, infection control, fire safety and legionella arrangements had improved.
- Effective?
- Requires improvement
- Staff training, supervision and appraisals were incomplete. There were particular gaps in recognising deteriorating health, choking and dysphagia, and supporting people with a learning disability. Nutrition support and work with health professionals were positive.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff listened to people's views, supported their independence and understood their individual needs.
- Responsive?
- Requires improvement
- Care was often person-centred, but records did not always describe all the support people needed. People had limited access to meaningful activities and some relatives had not been given the opportunity to review care plans.
- Well-led?
- Requires improvement
- The provider and deputy manager were visible and had started improvement work with outside organisations. However, quality checks were still not effective enough to identify and fix repeated problems, and this was the fourth consecutive inspection where regulations had not been met.
What inspectors found, July 2023
Rated Requires Improvement and remains in special measures; inspectors found caring staff but ongoing safety, staffing, records and activity concerns.
Inspectors visited over 6, 7 and 9 June 2023. This was an announced comprehensive inspection. They spoke with people, relatives, staff and health and social care professionals. They also checked care records, medicines records, recruitment files, training records and management systems.
There had been important improvements since the previous inspection. Medicines management, infection control, fire safety and legionella safety had improved. People were treated with kindness and respect. Health professionals said the home worked well with them, and people told inspectors they felt safe.
However, people were still not always protected from risks. Concerns included unsafe water temperatures, choking risks, delayed safeguarding reports, incomplete care records, gaps in staff training and limited meaningful activities. The provider remained in breach of five regulations. The overall rating improved from Inadequate to Requires Improvement, but the home remains in special measures.
Kind and respectful care
Inspectors saw warm and friendly interactions. People and relatives said staff respected dignity, privacy, choice and independence.
“We saw staff engaging with people during the inspection, seeking and acting on their views in a caring, warm and friendly manner.” from the report
Improved medicines safety
Medicines records gave assurance that medicines were administered as prescribed. Staff gained consent, signed records correctly and had their competence checked.
“The Medicine Administration Records (MAR) we reviewed provided assurance medicines were being given as prescribed.” from the report
Improved infection control
The provider worked with the infection prevention and control team. Inspectors were assured that infection risks, visitors, protective equipment and outbreaks were being managed.
“There had been significant improvement in this area since our last inspection.” from the report
Good partnership with health professionals
The home sought advice and helped people access health reviews, appointments and hospital care. Professionals said staff were positive, helpful and timely.
“A GP visits the home twice monthly and keeps on top of various health conditions appropriately and issues are not ignored or left.” from the report
Unmanaged safety risks
seriousSome water temperatures were unsafe, maintenance checks were incomplete and one person at risk of choking was not given food prepared as advised. The provider acted immediately after inspectors raised these issues.
“People living at Bafford House were not always protected from risks related to the premises, potential risks from others, or risks related to choking.” from the report
Safeguarding reports were delayed
seriousTwo safeguarding matters were not reported properly or promptly to external agencies. The provider was reminded of their responsibility to involve others.
“The provider had failed to establish and operate effective systems and processes to prevent abuse of service users and investigate any allegation or evidence of abuse.” from the report
Staff training and supervision gaps
needs fixingMandatory training, supervision and appraisals were incomplete. Training was also limited in recognising when people became unwell, dysphagia and choking, and supporting people with a learning disability.
“The provider had failed to ensure staff received appropriate training, supervision and appraisal in line with their own policies and training requirements.” from the report
Incomplete care records
needs fixingRecords did not always describe all the support people received or give staff clear guidance about people's needs and wishes. Some relatives and people had not seen or reviewed their care plans.
“People's care records did not always contain sufficient information to enable a person-centred approach and to accurately reflect people's needs.” from the report
Limited activities
needs fixingThere was no dedicated staff time to organise meaningful activities. Opportunities to go out or follow personal interests were limited and were usually provided only when requested.
“People had limited opportunities to follow their interests or take part in activities that were meaningful to them at Bafford House as there was no dedicated staff time to co-ordinate this.” from the report
Recruitment checks incomplete
seriousRecruitment records did not always include full employment histories, interview evidence or checks about overseas convictions and permission to work in the UK.
“The provider had not established safe recruitment procedures to ensure staff employed were suitable to support vulnerable adults.” from the report
- 01What has been done to make water temperatures, electrical fittings, taps, toilets, flooring and bathroom areas safe?
- 02How will you ensure every person at risk of choking has a current assessment and receives food and drinks prepared exactly as advised?
- 03What is the timetable for completing staff training, supervision and appraisals, including training about learning disability, dysphagia and recognising deterioration?
- 04How will you improve care records and make sure families can review and update their relative's support plan?
- 05Who will organise regular meaningful activities and outings, and how will you make sure opportunities are offered fairly?
This was an announced comprehensive inspection covering all five key questions, including infection prevention and control; the previous overall rating was Inadequate and the service had been in special measures since 2 December 2022. This explanation was written from the published report of 28 July 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, December 2022
Rated Inadequate; inspectors found unsafe care, poor management of risks and medicines, and insufficient staff training and recruitment.
Inspectors visited Bafford House unannounced in October 2022 to check the safety, effectiveness, responsiveness, and leadership of the care home. They looked at the environment, spoke with people living there, relatives, staff, and professionals, and reviewed records and policies.
They found serious problems with how risks to people's health and safety were managed, including fire safety, infection control, and falls prevention. Medicines were not always given safely, and records were inaccurate. The home was not clean enough, and some hazardous products were not stored safely.
There were not enough trained and experienced staff to meet people's needs properly. Staff recruitment was not done safely, and many staff had not completed essential training. Care plans were not always up to date or detailed enough to guide staff.
The provider's systems for checking and improving the quality of care were ineffective. They had not acted on previous inspection findings, and there was no formal way to gather feedback from people, relatives, or staff to improve the service.
Access to healthcare
People had access to medical support including GPs, chiropody, and community health professionals.
“People had access to medical support and review by a GP or emergency services when needed.” from the report
Respect for consent and best interests
Care was provided with consent or in people's best interests following legal requirements.
“People were supported in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.” from the report
Unsafe risk management
seriousFire safety checks were incomplete, infection risks were not controlled, and environmental hazards were not addressed.
“Fire safety risks had not been appropriately mitigated as the provider had not robustly implemented their fire risk assessment.” from the report
Poor medicines management
seriousMedicines were not always given as prescribed, records were inaccurate, and expired medicines were stored unsafely.
“Systems were not in place to ensure the proper and safe management of people's medicines. This put people at risk from the impact of medicines errors.” from the report
Insufficient and untrained staff
seriousThere were not enough staff, many lacked training, and recruitment checks were incomplete, risking unsafe care.
“There continues to be insufficient suitably qualified, competent and skilled staff deployed to fully meet people's needs and to cover the routine work of the service.” from the report
Poor quality monitoring
seriousThe provider failed to identify or fix ongoing problems, including staff training, recruitment, and care records.
“The provider's quality monitoring processes had not improved since our last inspection.” from the report
Limited activities and choice
needs fixingPeople had few opportunities for meaningful activities and limited meal choices.
“There was no plan of activities and no activity records recording what activities may have taken place.” from the report
- 01What steps have you taken since this inspection to improve staff training and recruitment?
- 02How do you ensure medicines are given safely and records are accurate?
- 03What plans are in place to improve the cleanliness and safety of the environment?
- 04How do you support people to have meaningful activities and choices at mealtimes?
- 05How do you gather and act on feedback from people, relatives, and staff to improve the service?
This was a comprehensive inspection covering Safe, Effective, Responsive, and Well-led key questions. This explanation was written from the published report of 2 December 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bafford House
9 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- July 2023Requires improvementcurrent ratingup from InadequateSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- December 2022Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- July 2022Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- December 2021Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- July 2019Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2018Requires improvementstayed Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- August 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Inadequate
- December 2016Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- January 2016Requires improvementSafe: Requires improvementEffective: InadequateCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- October 2021
Registered with the Care Quality Commission on 28 October 2021.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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38 live-in carers within about an hour of Gloucestershire
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £1,030 to £1,360 a week. 31 can care for a couple. 12 years' experience on average.
“She was very caring, kind and patient to all his needs, she built up a wondetful rapport with him, she was dedicated and was there for him through good times as well as through the tough times”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.