CQC report explained · a nursing home
What the CQC found at Bishop's Cleeve Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, January 2024
Requires Improvement; inspectors found risks, medicines and management systems were not always safe or effective.
This was an unannounced focused inspection on 14 and 15 November 2023. Inspectors reviewed safe, effective and well-led care. They spoke with people, relatives, staff and visiting professionals, and checked care records, medicines, staff files and management records.
People and relatives generally said people felt safe and received good care. Inspectors also found important shortfalls. Risk assessments and staff guidance were not always clear, medicines were not always managed safely, and some people were not supported in line with their choices or legal rights.
The home was rated Requires Improvement overall. Safe, effective and well-led were each rated Requires Improvement. Caring and responsive were not inspected during this visit, so their previous ratings carried over when the overall rating was calculated.
The provider breached regulations covering safe care and treatment, safeguarding and improper treatment, person-centred care, and good governance. The provider was given warning notices for safe care and treatment and good governance. The provider paused admissions for four weeks after the inspection and was asked to provide an action plan.
People felt safe
People and relatives consistently said they felt safe. Inspectors also saw staff respond promptly to meals and support needs.
“People and relatives told us they felt people were safe and that the care provided was good.” from the report
Clean environment
Inspectors found the home clean and without unpleasant smells. People and relatives also praised the cleanliness of rooms and the environment.
“We observed the home to be clean and there were no malodours.” from the report
Safe recruitment
The required checks were completed before new staff started work, including criminal record checks.
“Staff were recruited safely. All required checks were made before new staff began working at the home.” from the report
Access to healthcare
People were supported to access GPs, dentists, opticians, chiropody and other health professionals. Visiting healthcare professionals gave positive feedback.
“Records showed people were supported to access support from healthcare professionals such as speech and language therapists, occupational therapists and physiotherapists.” from the report
Early management action
The interim manager had identified shortfalls and started actions, including reviewing incidents, improving communication and making missing legal referrals.
“The interim manager had taken immediate action to improve communication and governance processes.” from the report
Risk management
seriousRisk assessments and reviews for eating and drinking, mobility, falls and moving and handling were not always robust. Staff did not always have clear guidance on how to keep people safe.
“People's risks were not always robustly assessed and reviewed.” from the report
Medicines
seriousMedicine patches, 'when required' medicines, expiry dates and a cream not listed on the medicine record were not always managed safely. One person's medicines were given in a way that did not follow their plan.
“Medicines are not always managed safely for people living at the service.” from the report
Mental capacity and liberty safeguards
seriousTen of 19 people identified as needing legal referrals had not been referred until inspectors asked about this. Some mental capacity records were also incomplete or not decision-specific.
“This placed people at risk of unlawful deprivation of their liberty.” from the report
Person-centred care
needs fixingPeople were not always involved in their care or supported to make choices. Inspectors saw limited meaningful engagement, including periods of up to 45 minutes for some people living with dementia.
“We observed people living with dementia going for periods of time, sometimes 45 minutes, without any meaningful engagement from staff.” from the report
Weak oversight
seriousAudits had not been carried out routinely since August 2023. There were no effective audits for medicines, clinical governance or care plans, and there was no clear service improvement plan.
“There were no audit processes in relation to the management of medicines, clinical governance and care plan audits.” from the report
Fire and infection checks
seriousSystems did not ensure fire and legionella checks continued when the responsible person was absent. Hazardous substances were accessible, and infection control audits were not being completed.
“The service had not implemented a system to ensure fire and legionella safety checks were being carried out in the absence of the person responsible for completing these.” from the report
- 01What has changed to make risk assessments and staff guidance clear for falls, mobility, moving and handling, and eating and drinking?
- 02How are you checking that medicines are given exactly as each person's plan requires, including patches and 'when required' medicines?
- 03Have all people who need a Deprivation of Liberty Safeguards referral now been referred, and are mental capacity assessments decision-specific?
- 04What audits are now being completed for medicines, care plans, clinical governance, fire safety and infection control?
- 05How will people living with dementia receive regular meaningful engagement and have their choices acted on?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected during this visit and their previous ratings carried over into the overall rating. This explanation was written from the published report of 17 January 2024 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, August 2022
Rated Good overall, with Outstanding leadership; inspectors found kind, personalised care, safe medicines and strong systems for learning and improvement.
This was the home's first inspection since registration. It was unannounced and took place on 12 and 13 July 2022. Inspectors spoke with people living there, relatives, staff and health and social care professionals. They also reviewed care records, medicines records, recruitment records and management information.
The home was rated Good for Safe, Effective, Caring and Responsive. People were protected from abuse, received medicines safely and had enough staff to meet their needs. Staff knew people's preferences, treated them with dignity and supported a range of activities and community links.
The home was rated Outstanding for Well-led. Inspectors found strong leadership, detailed checks on quality, an open culture and evidence that the home learned from incidents and feedback. Two issues were identified: one falls care plan did not include extra considerations linked to blood-thinning medicine, and an emergency caused a delay to meals on one day.
Safe medicines
Medicines were stored, given and recorded safely. Staff had training and regular checks of their competence.
“People received their medicines in a safe and timely way.” from the report
Kind, individual care
Staff knew people's preferences and supported their dignity, independence and choices.
“Staff treated people with kindness, dignity and respect and spent time getting to know them.” from the report
Activities and community links
People could join varied activities and were supported to stay connected with the local community.
“A programme of activities was in place to encourage people to join in and socialise if they wanted to.” from the report
Strong leadership
Managers were open and approachable. Quality checks, feedback and learning were built into how the home was run.
“Robust quality assurance systems and a strong learning culture across the organisation contributed to continual development and improvement of the home.” from the report
Falls plan did not include blood-thinning medicine
needs fixingOne person's falls care plan did not include extra considerations linked to anti-coagulant medication. The manager said this would be added.
“However, anti-coagulant medication had not been scoped into people's falls care plan.” from the report
Delay to meals during an emergency
needs fixingAn emergency in the home delayed meals on one inspection day. The manager reviewed what had happened and considered measures to reduce the chance of this happening again.
“On one day there was an emergency within the home which impacted upon mealtime and resulted in a delay in servicing people's meals.” from the report
- 01What was added to the falls care plan for people taking anti-coagulant medication?
- 02What changes have been made to make sure meals are not delayed if there is another emergency?
- 03How are people's care plans reviewed when their needs, wishes or preferences change?
- 04How do you check that staffing levels remain enough when people need more support?
- 05Which activities and community links are currently available to residents who want to take part?
This was the home's first comprehensive inspection, covering all five key questions, the premises, care provided and infection prevention and control arrangements. This explanation was written from the published report of 13 August 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 Bishop's Cleeve Care Home
2 rated inspections over a year: the service has slipped, from Good to Requires improvement.
- January 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2022GoodSafe: GoodEffective: GoodWell-led: Outstanding
- February 2022
Registered with the Care Quality Commission on 1 February 2022.
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”
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