CQC report explained · a residential care home
What the CQC found at Bedborough 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 damaged and unclean areas, infection risks and smoking close to people's accommodation. Staffing levels, safeguarding processes and medicines management were satisfactory.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous rating was used to calculate the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. Inspectors did observe person-centred interactions and staff speaking positively about people.
- Responsive?
- Good
- The home provided personalised care and supported communication and relationships. Inspectors found that activities were limited and were not always recorded properly.
- Well-led?
- Requires improvement
- Checks and audits had not consistently identified or addressed problems with the premises, consent practice and activities records.
What inspectors found, March 2023
Bedborough House was rated Requires Improvement; inspectors found kind, personalised support but serious problems with the building, consent and quality checks.
This was an unannounced focused inspection on 6 and 7 February 2023. Two inspectors and an Expert by Experience spoke with people, staff and relatives, checked records and toured the home.
The home was not always safe. Inspectors found damaged and dirty areas, infection risks and staff smoking close to people's accommodation. They also found that some decisions were not made properly under the Mental Capacity Act.
Staff numbers were sufficient and medicines were managed safely. People received personalised support, help with communication and support to keep in touch with relatives and friends. However, activities were limited and records did not always show what people had done.
The overall rating fell from Good to Requires Improvement. Safe and Well-led were rated Requires Improvement. Responsive remained Good, while Effective and Caring were not inspected during this visit and their previous ratings were used.
Enough staff
Rotas showed there were enough staff to keep people safe, and planned one-to-one hours were consistently provided.
“There were sufficient numbers of staff to keep people safe.” from the report
Personalised support
Care assessments included people's needs, choices, communication methods and hoped-for outcomes. Staff were observed interacting with people in a person-centred way.
“Staff spoke about and treated people in a person-centred way.” from the report
Medicines management
Medicines were stored securely and staff had guidance for medicines given when needed and for epilepsy management. Inspectors found evidence that overmedication was being reduced.
“Medicines were managed safely.” from the report
Communication and relationships
People were supported to communicate in ways that suited them and to maintain important relationships with relatives and friends.
“People were supported to maintain relationships with relatives and friends important to them.” from the report
Unsafe and poorly maintained areas
seriousInspectors found a missing external door lock, a broken fence, protruding nails, damaged walls and other damaged surfaces. Some areas were visibly unclean, creating risks of physical harm and infection.
“Areas of the service were damaged or broken.” from the report
Smoking near accommodation
seriousStaff were seen smoking close to people's accommodation. Smoke could be smelled inside the communal lounge, and there was no risk assessment for this.
“We observed staff smoking in the communal garden and in close proximity to people's accommodation.” from the report
Consent and privacy concerns
seriousA video monitor showed a live stream from a person's private accommodation in a communal kitchen. Records did not show consent or consideration of less restrictive options, and some food decisions lacked supporting information.
“This meant staff and people using the kitchen could see the person unnecessarily; this was not the least restrictive option.” from the report
Weak quality checks
seriousAudits had not identified important problems, including failures in consent practice and long-standing damaged flooring. The home also lacked a robust plan to improve activity records.
“Checks and audits had not always been used effectively to identify the shortfalls we found during our inspection.” from the report
Limited activities
needs fixingPeople had access to a limited range of activities. Staff said they could not always support meaningful activities because too few staff were trained to drive, and records were incomplete.
“The registered manager confirmed activities provision was an area for development and said staff did not always document when they supported people to access activities.” from the report
- 01What repairs and cleaning work have been completed since the inspection, including the external door lock, broken fence, damaged walls, flooring and soft furnishings?
- 02How do you now prevent staff smoking close to people's accommodation, and what risk assessment is in place?
- 03How do you record consent and best-interest decisions for monitoring equipment, food and fluids?
- 04How are you checking that audits identify problems and that agreed improvements are completed promptly?
- 05What has changed to increase meaningful activities, including the number of staff trained to drive, and how are activities now recorded?
This was a focused inspection of Safe and Well-led only; the Effective and Caring ratings were not inspected and the previous ratings were used, while Responsive remained rated Good. This explanation was written from the published report of 8 March 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, January 2021
Bedborough House was rated Good; inspectors found major improvements, with some care records still needing updates.
Inspectors visited on 16 and 17 December 2020 without announcing the visit. They spoke with the manager, staff and relatives, and checked care records, medicines records, staff files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safer medicines systems, personalised care, support for independence and better leadership.
This was a significant improvement from the previous inspection in July 2019, when the home was rated Inadequate and had several breaches. The home was in special measures after that inspection, but it is no longer Inadequate, in breach or in special measures.
Improved safety
Inspectors found that safeguarding concerns were reported, risks were assessed and incidents were reviewed. The home had stopped relying on agency staff to cover shifts.
“The service was no longer relying on agency staff to cover shifts.” from the report
Choice and independence
People had one-to-one and two-to-one staffing available for activities and community access. Flats had kitchenettes to help people develop their independence.
“People were supported to have maximum choice and control of their lives” from the report
Kind and person-centred care
Staff knew people well, supported day-to-day choices and encouraged people to do as much as they could for themselves.
“We observed positive interactions between people and staff.” from the report
Better leadership
The provider had action plans, audits and regular management oversight. Relatives and staff reported that communication and leadership had improved.
“The provider's quality assurance systems and processes had improved.” from the report
Some medicines information was incomplete
needs fixingPlans for some when-required medicines did not include all the information staff needed. Staff said they would review and update the documents.
“Some of the plans in place to support the use of 'when required' medicines did not always contain all the information” from the report
Some health records needed updating
minorOne person's monitoring records did not match their care plan, and one health action plan needed an update. The manager said these would be addressed.
“We found one instance where a person's records were not completed in line with their care plan.” from the report
Registered manager vacancy
minorThe home had an acting manager who was not registered with CQC. The provider was advertising for a registered manager.
“The service had an acting manager, they were not registered with the Care Quality Commission.” from the report
- 01How have you updated the plans for when-required medicines, and how do you check that staff have the information they need?
- 02Which parts of my relative's health action plan and monitoring records need updating, and have those updates been completed?
- 03Who is currently responsible for managing the home while the acting manager is in post?
- 04How will you provide one-to-one or two-to-one support for my relative's preferred activities and community visits?
- 05How do you make sure action plans and audits lead to lasting improvements?
This was an unannounced planned inspection that assessed all five key questions; the report says it was arranged because of the previous Inadequate rating. This explanation was written from the published report of 19 January 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.
Every inspection of Bedborough House
4 rated inspections over 5 years: the service has slipped, from Good to Requires improvement.
- March 2023Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2021Goodup from InadequateSafe: GoodResponsive: GoodWell-led: Good
- May 2020Inadequatedown from GoodSafe: InadequateEffective: InadequateCaring: InadequateResponsive: InadequateWell-led: Inadequate
- August 2018GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017
Registered with the Care Quality Commission on 29 March 2017.
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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