CQC report explained · a nursing home
What the CQC found at Bedford Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, September 2021
Rated Good overall; inspectors found safe, responsive and well-led care, but effectiveness still Requires Improvement.
Inspectors visited the home on four days in late July and early August 2021. They spoke with people living there, relatives, staff and a visiting professional. They also reviewed care records, medicines records, staff files, audits and other documents.
The home was rated Good overall. Safe, Responsive and Well-led were rated Good. Inspectors found safe medicine management, suitable staffing arrangements, good infection control and systems for checking quality. People said they felt safe, although some said staff were too busy to spend much time chatting.
Effective was rated Requires Improvement. Records of personal care, oral care, food and drink, and positional changes were not always complete. The home also needed to improve dementia-friendly personalisation and navigation around the building. The report says improvements had been made since the previous inspection, and the home was no longer in breach of regulations.
This was a focused inspection. The Caring rating was not assessed during this visit, and the previous rating was used in calculating the overall result.
Safe medicines
Medicines were administered and stored safely, with suitable guidance for medicines given only when needed. Controlled medicines were also managed correctly.
“Medicines were administered in a safe and caring way, with action taken when medicine incidents or errors occurred.” from the report
Infection control
Inspectors found good infection prevention practice, including cleaning, protective equipment and risk assessments.
“At this inspection we found IPC practice continued to be of a good standard.” from the report
Health support
People could access a range of health professionals, and information from appointments and assessments was recorded.
“People had access to a variety of medical and health related services, such as general practitioners, speech and language therapists, tissue viability nurses and dieticians.” from the report
Quality monitoring
The provider and manager used audits, meetings and an improvement plan to track problems and actions.
“The provider and registered manager used a range of systems and processes to assess the quality and performance of the home and care provided.” from the report
Care records were incomplete
needs fixingSome personal and oral care records, and records of positional changes, were incomplete. The manager said staff were still adjusting to the new electronic system.
“Although record keeping had improved, we identified some gaps in personal and oral care charts and the documenting of positional changes.” from the report
Food and drink records needed more detail
needs fixingPeople received enough food and drink, but records did not always clearly show what and how much people had eaten or whether supplements had been given.
“However, at times greater detail was required to explain exactly what and how much people had eaten, or that supplements and fortification had been provided.” from the report
Dementia-friendly environment
minorMore work was needed to help people living with dementia find their way around and recognise their bedrooms.
“Bedroom doors had been painted in bright colours, however, we found little in the way of personalisation to help people identify their bedroom” from the report
Activities were limited
needs fixingThe home had fewer activity coordinators than needed. A weekly activity was planned for each unit, but people gave mixed views about whether enough was available.
“The home had lost two of its activity coordinators and despite advertising for the positions, had yet to fill these.” from the report
Staff had limited time to chat
minorStaffing levels were judged sufficient to meet people's needs, but staff said they were very busy and had limited time for conversation.
“Staff members confirmed they were very busy and had limited time to sit and chat with people but confirmed staffing levels allowed them to meet people's needs and keep them safe.” from the report
- 01What checks now show that personal care, oral care and positional changes are recorded every time?
- 02How do you record exactly what each person eats and drinks, including supplements and fortified food?
- 03What changes have been made to help people living with dementia recognise their bedrooms and find their way around?
- 04How many activity staff are currently in post, and how often does each unit receive activities?
- 05What was the outcome of the concerns raised in the staff survey about management and support?
This was a focused inspection of Safe, Effective, Responsive and Well-led; Caring was not inspected and the previous rating was used in calculating the overall rating. This explanation was written from the published report of 14 September 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 2021
Inspected but not rated; inspectors found strong infection prevention and safe visiting arrangements.
The CQC made an unannounced, targeted inspection on 20 July 2021. It looked at infection prevention and control during the coronavirus pandemic.
Inspectors were assured that the home managed visitors, testing, personal protective equipment, cleaning, social distancing and infection outbreaks safely. They also found that visits were being supported through dedicated rooms, a visiting pod and other ways to keep in touch.
The home was inspected but not rated. This means the inspection did not give a new overall quality rating or a rated judgement for the other four questions.
Safe visiting
The home used risk assessments, temperature checks and lateral flow tests for visitors. It provided separate visiting rooms and a pod to limit access to the wider home.
“Visiting was being facilitated in line with local and government guidance.” from the report
Cleaning
Inspectors found the premises clean and said cleaning arrangements had been strengthened during the pandemic, including regular cleaning of frequently touched surfaces.
“The premises looked and smelled clean. The home had robust cleaning procedures in place, which had been amended in response to the pandemic.” from the report
Protective equipment
There was a plentiful supply of protective equipment. Staff had training and competency checks on using it correctly.
“The home had a plentiful supply of PPE, which was worn correctly and consistently by staff.” from the report
Regular testing
The home had regular testing for staff and residents, following government guidance.
“A robust testing regime was in place, which followed government guidance.” from the report
Inspectors raised no specific concerns in this report.
- 01Are the visitor risk assessments, testing arrangements and dedicated visiting areas still in place?
- 02How often are staff and residents tested now, and what happens if someone tests positive?
- 03How do you check that staff are using protective equipment correctly?
- 04How are frequently touched areas cleaned, and how is this checked?
- 05How do you manage isolation, separation and infection outbreaks when needed?
This was an unannounced targeted inspection of infection prevention and control only; the service was inspected but not rated and the report did not assess the other four questions. This explanation was written from the published report of 27 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.
Every inspection of Bedford Care Home
4 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- September 2021Goodcurrent ratingSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Good
- July 2021Inspected but not ratedSafe: Inspected but not rated
- April 2020Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2019Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- November 2017
Registered with the Care Quality Commission on 30 November 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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