CQC report explained · a nursing home
What the CQC found at Bagshot Park Care Centre
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found enough staff, suitable risk assessments, safe medicines management and effective infection prevention measures. Staff understood safeguarding and emergency evacuation procedures.
- Effective?
- Good
- Staff had relevant training, supervision and support. People had access to healthcare, suitable food and drink, and care that took account of their capacity and choices.
- Caring?
- Good
- This question was not separately rated in this inspection report. People and relatives described staff as kind, caring and respectful.
- Responsive?
- Good
- This question was not separately rated in this inspection report. The report says people and relatives could give feedback, attend meetings and raise complaints.
- Well-led?
- Good
- The home had regular audits, provider oversight and an approachable registered manager. People, relatives and staff described a positive atmosphere and said concerns were dealt with promptly.
What inspectors found, June 2023
Rated Good; inspectors found safe, kind and well-managed care, with improvements since the previous Requires Improvement rating.
Inspectors visited the home on 11 May 2023 and reviewed information through 19 May 2023. The inspection was unannounced. They spoke with people, relatives, staff and healthcare professionals, and reviewed care records, medicines records, recruitment files and quality checks.
The home was rated Good overall. Safe, Effective and Well-led were each rated Good. People and relatives said staff were kind, caring and helped them feel safe. Inspectors found enough staff, safe medicines management, suitable risk plans and good infection control.
The home had improved since the previous inspection. Effective and Well-led had changed from Requires Improvement to Good. Previous recommendations about temporary staff training, capacity assessments, DoLS applications and clearer care plans had been addressed.
The report does not give separate ratings for Caring or Responsive. CQC said it will continue to monitor information received about the home.
People felt safe
People and relatives said they felt safe. Staff understood safeguarding procedures and knew how to report concerns.
“People and their relatives told us they felt safe living at Bagshot Park Care Centre.” from the report
Safe medicines
Medicines were stored, given and recorded safely. Inspectors found no gaps in the medicine administration records and saw medicines being given in a person-centred way.
“People's medicines were received, stored and administered safely.” from the report
Good partnership working
Staff worked with healthcare professionals to support people's health and reduce avoidable hospital visits.
“Healthcare professionals told us staff referred people appropriately and supported people to access healthcare services effectively.” from the report
Improved management
The home had regular audits and oversight of areas such as medicines, incidents, call bells, training and safety. The manager acted on minor issues during the inspection.
“There were systems in place to monitor the quality of the care provided.” from the report
Minor medicines storage issue
minorInspectors identified a minor area for improvement with medicines storage. The provider ordered a new shelving unit immediately during the inspection.
“Where we highlighted minor areas for improvement during the inspection, the registered manager proactively addressed this immediately and involved people and staff in the process.” from the report
- 01What changes were made to medicines storage after the inspection, and how is this now checked?
- 02How will you make sure agency staff continue to receive the right training before working here?
- 03How are my relative's personal choices and preferences recorded and reviewed?
- 04How can relatives raise concerns, give feedback and attend residents' or relatives' meetings?
- 05How will you keep us informed about significant incidents or changes in our relative's care?
The inspection rated Safe, Effective and Well-led; Caring and Responsive were not separately rated in this report. This explanation was written from the published report of 20 June 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, September 2020
Targeted inspection not rated; inspectors found safe care systems and good communication, while the previous overall rating remained Requires Improvement.
Inspectors carried out a targeted inspection on 21 August 2020 after receiving anonymous concerns about people's care, infection control, management and staff culture. They spoke with two people, 21 staff members and 12 relatives. They also reviewed care records, complaints, accident records, audits and cleaning information.
The inspectors found that people were generally safe, risks were assessed and staff understood safeguarding. Infection control arrangements followed national COVID-19 guidance. There were enough staff with suitable skills, although the home was replacing agency staff with permanent staff. Staff and families described better teamwork, support and communication.
This was not a full inspection, so the home was not given new ratings. The previous overall rating remained Requires Improvement. Safe was previously Good and Well-led was previously Requires Improvement. Both were marked Inspected but not rated at this visit.
Safeguarding
Staff understood how to recognise and report abuse. The provider had investigated the anonymous concerns and acted where further action was needed.
“Staff had received safeguarding training and understood their responsibilities in safeguarding people from abuse.” from the report
Risk management
Care plans covered important risks such as skin damage, nutrition, mobility and personal care. Specialist care had additional plans and competency checks.
“Risk management plans were comprehensively completed and covered areas including skin integrity, nutrition, mobility and personal care.” from the report
Infection control
The home followed COVID-19 guidance, used protective equipment and increased cleaning of frequently touched areas.
“The service followed the latest national guidance in relation to infection prevention and control.” from the report
Family communication
Families received regular updates during visiting restrictions and were helped to keep in contact using technology.
“Every day we had an update, brilliant as reassurance, as restrictions have eased it's now done weekly by email.” from the report
Teamwork and staff support
Inspectors saw staff working well together. Staff said they received training, induction and support during the pandemic.
“There was a positive atmosphere in the service and staff were observed to work well as a team.” from the report
Ongoing safety investigation
seriousOne relative had raised safety concerns about their loved one's care. The report says this remained part of an ongoing complaint and safeguarding investigation.
“This is part of an on-going complaint and safeguarding investigation.” from the report
Staff turnover
minorA relative reported high staff turnover. The home was replacing agency staff with permanent staff, which was intended to improve consistency.
“There seems to be a high turnover of staff at the moment. They're replacing the agency with permanent staff.” from the report
Person-centred care concern
needs fixingOne relative felt the home had not always responded in a person-centred way in one part of their loved one's care. Management said it would review this.
“One relative expressed they felt the service had not always responded in a person-centred way in relation to a specific part of their loved one's care.” from the report
Sluice room door
minorA spot check found the sluice room door was not fully closed and locked. Staff were reminded, and inspectors found it locked during their visit.
“One spot check highlighted the sluice room door was not fully closed and locked.” from the report
- 01What was the outcome of the ongoing complaint and safeguarding investigation about safety?
- 02How has replacing agency staff with permanent staff affected continuity and consistency of care?
- 03What changes were made after the concern about person-centred care?
- 04How are risk assessments and specialist care plans checked and updated?
- 05What were the results of the next comprehensive inspection and the current ratings?
This was a targeted inspection of specific parts of Safe and Well-led, including infection control and management concerns; it did not assess the full five key questions, so the previous overall rating remained Requires Improvement. This explanation was written from the published report of 26 September 2020 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 Bagshot Park Care Centre
2 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- June 2023Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- March 2020Requires improvementSafe: GoodEffective: Requires improvementWell-led: Requires improvement
- February 2019
Registered with the Care Quality Commission on 14 February 2019.
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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