CQC report explained · a residential care home
What the CQC found at Bavani Care Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, staffing, recruitment and infection control were well managed, but some risk plans were not sufficiently detailed or person-centred.
- Effective?
- Good
- Staff had the training and support needed, including training about mental health and positive behavioural support. People received suitable food, health care and support that respected their choices.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were supported to make decisions and develop independent living skills.
- Responsive?
- Good
- Care plans reflected people's needs, preferences and interests. People were supported with activities, relationships, communication and complaints.
- Well-led?
- Good
- The home had clear management arrangements and regular checks on quality and safety. Managers listened to people, relatives, staff and health and social care professionals and used feedback to improve the service.
What inspectors found, July 2021
Bavani Care Home Limited was rated Good overall; inspectors found safe, kind and personalised care, but some risk plans needed more detail.
This was an unannounced comprehensive inspection on 15 June 2021. The inspectors spoke with five people living at the home, staff and managers. They also reviewed care plans, staff files, medicine records and other documents, and received feedback from a relative and a mental health professional.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People said they were happy with the care. Inspectors found enough staff, safe medicines systems, clean premises and good infection control. Staff were trained and supported, and people received care suited to their needs and choices.
The main shortfall was that some risk management plans were not detailed or personal enough. Inspectors recommended improving them. This was not recorded as a breach of regulations.
The previous overall rating, published in July 2020, was Requires Improvement. Inspectors found that improvements had been made and sustained, so the home was now rated Good overall and in all five areas.
Safe medicines
Medicines were organised safely, and inspectors found no recording errors or omissions in the records they checked.
“No recording errors or omissions were found on completed medicines records we looked at.” from the report
Kind and respectful staff
People were treated warmly and with respect. Staff supported privacy, dignity and people's individual cultural and spiritual needs.
“Staff interaction with people was characterised by warmth and kindness.” from the report
Support for independence
People were encouraged to build everyday skills, make choices and take part in activities that mattered to them.
“At this inspection we found the provider had taken action to promote people's independence.” from the report
Improved staff training
The home had addressed the earlier concern about staff knowledge and support. Staff had completed relevant training, including positive behavioural support.
“At this inspection we found enough improvement had been made to address this outstanding training issue.” from the report
Open management
Managers monitored the service, sought feedback and worked with health and social care professionals.
“The provider promoted an open and inclusive culture which sought the views of people living in the care home, their relatives and staff.” from the report
Inspectors raised no specific concerns in this report.
- 01How will you make sure each person's risk management plan gives staff clear, personal instructions?
- 02How often are risk management plans reviewed, and who is involved in those reviews?
- 03How do you make sure staff understand what to do if someone becomes distressed or shows behaviour that may be difficult to manage?
- 04What training do staff receive about mental health and positive behavioural support, and how is their competence checked?
- 05How will you support my relative to build or maintain independent living skills and take part in activities they enjoy?
This was an unannounced planned comprehensive inspection covering all five key questions and the home's infection prevention and control arrangements. This explanation was written from the published report of 6 July 2021 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, July 2020
Overall rated Requires Improvement; Safe and Well-led improved to Good, but the other areas were not inspected.
Inspectors visited over three days in July 2020. They spoke with people living in the home, relatives, staff and managers. They reviewed care plans, medicines records, staff files and fire safety documents.
They found medicines were now managed safely. Records were complete, allergies were recorded and staff training and checks had improved. Fire doors had also been repaired, and staffing, safeguarding and infection control were considered adequate.
The home was rated Good for Safe and Good for Well-led. However, this was a focused inspection. The other three areas were not inspected, so their previous ratings were used. This meant the overall rating remained Requires Improvement.
Medicines were safer
Medicines records were complete and allergy information was recorded. Staff training, competency checks and audits had also improved.
“Medicines systems were now well-organised, and people continued to receive their medicines as prescribed.” from the report
Fire safety improved
The fire-resistant doors tested by inspectors closed automatically. Emergency evacuation plans and regular fire drills were in place.
“We saw fire-resistant doors we tested at random during this inspection all closed automatically into their doorframes.” from the report
People felt safe
People said staffing was adequate and they felt safe. Staff understood the risks people might face and how to manage them without unnecessarily restricting freedom.
“All the people we spoke with said Bavani Care Home was adequately staffed and they felt safe living there.” from the report
Inspectors raised no specific concerns in this report.
- 01What were the previous ratings for Effective, Caring and Responsive, and what work has been done in each area since that inspection?
- 02How often are medicines audits and staff competency checks now completed, and can families see how problems are followed up?
- 03How are people's views used in house meetings and in decisions about their care and activities?
- 04What changes were made after the incident of challenging behaviour, and how are weekend staffing levels decided?
- 05When is the next full inspection or review expected, and what improvements does the home still plan to make?
This was a focused inspection of Safe and Well-led only; the ratings for Effective, Caring and Responsive were carried over from the previous comprehensive inspection. This explanation was written from the published report of 24 July 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 Bavani Care Home Limited
4 rated inspections over 2 years: the service has improved, from Requires improvement to Good.
- July 2021Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2020Requires improvementstayed Requires improvementSafe: GoodWell-led: Good
- December 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- May 2019Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- April 2018
Registered with the Care Quality Commission on 12 April 2018.
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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