CQC report explained · a nursing home
What the CQC found at Bishops Manor
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors were assured about infection prevention, protective equipment, testing, safe admissions, visiting arrangements and the management of outbreaks. The provider also said it had measures to reduce the effect of COVID-19-related staffing pressures.
- Effective?
- Good
- This area was not assessed in this targeted inspection.
- Caring?
- Good
- This area was not assessed in this targeted inspection.
- Responsive?
- Good
- This area was not assessed in this targeted inspection.
- Well-led?
- Good
- This area was not assessed in this targeted inspection.
What inspectors found, February 2022
Inspected but not rated; inspectors found good infection control arrangements and support for people isolating.
This was an announced, targeted inspection on 21 January 2022. Inspectors looked mainly at infection prevention and control, visiting arrangements and whether COVID-19 staffing pressures affected care.
The inspectors were assured that the home was managing infection risks. This included the use of protective equipment, testing, cleaning, social distancing, safe admissions and visits. The home was also meeting the COVID-19 vaccination requirement for staff and visiting professionals.
People were offered support and activities, including extra activities for anyone self-isolating. The home could reduce infection risks between its separate floors and had emergency boxes ready for an outbreak.
The home was inspected but not rated. This was not a full inspection of all five areas of care, so it does not provide an overall Good or Outstanding rating.
Support during isolation
Support and activities were available across the home. Extra activities were offered to people who were self-isolating.
“Support and activities were offered throughout the home with additional activities provided if a person is self-isolating.” from the report
Reducing infection spread
The home could reduce infection risks between its separate floors.
“The service can effectively minimise risk of infection between their separate floors.” from the report
Outbreak preparation
Emergency boxes were prepared so equipment could be reached quickly if there was an outbreak.
“Premade emergency boxes available in case of outbreak, allowing quick access to equipment as required.” from the report
Infection control arrangements
Inspectors were assured about protective equipment, testing, hygiene, admissions and visiting arrangements.
“We were assured that the provider was using PPE effectively and safely.” from the report
Inspectors raised no specific concerns in this report.
- 01How are you currently managing staffing pressures linked to COVID-19 or other infections?
- 02How do you provide activities and support when someone is self-isolating?
- 03How are visits managed, and what happens if there is an infection outbreak?
- 04How do you keep infection risks separate between the different floors?
- 05How quickly can staff access the emergency outbreak equipment?
This was a targeted inspection of infection prevention and control, visiting arrangements and COVID-19 staffing pressures; it did not provide ratings for the other care areas. This explanation was written from the published report of 11 February 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.
What inspectors found, November 2019
Gracewell of Sutton Coldfield is rated Good; inspectors found kind, personalised care, but two safeguarding incidents were not reported promptly.
This was an unannounced inspection on 12 and 13 September 2019. Inspectors spoke with people, relatives, staff and a health professional. They observed care and reviewed care plans, medicines records, staff recruitment files and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicines management, suitable training and good support from health professionals.
People were treated with kindness and respect. Staff knew people's histories and preferences well. There were activities for different interests, and the memory care floor had been designed to support people living with dementia.
There were some management concerns. Two safeguarding incidents had not initially been reported to the local authority or CQC. Inspectors also found some inconsistent records about pressure relief and catheter care. The Caring rating fell from Outstanding at the previous inspection to Good, while the other ratings stayed the same.
Enough staff
Inspectors found enough staff to meet people's needs. The home did not use agency staff, and staffing on the memory care floor had been increased at certain times.
“The service did not use agency staff and absence was covered within the staff team.” from the report
Kind and respectful care
Staff had a person-centred approach and supported people's dignity, independence and choices.
“There was a positive caring culture and staff were patient and kind.” from the report
Personalised activities
Activities were matched to people's interests and needs. Inspectors saw different activities taking place, including exercise and reminiscence sessions.
“The service used the Pool Activity Level (PAL) tool, to assess people's individual interests with a view to plan activities that best supported them.” from the report
Safe medicines
Medicines were stored, given and disposed of by trained staff. Inspectors found the medicine administration records they checked were complete.
“Medicines were managed safely and in line with good practice guidance.” from the report
Safeguarding referrals were late
seriousTwo safeguarding incidents were not reported to CQC or referred to the local authority when they happened. They were referred retrospectively before the inspection.
“There were two safeguarding incidents which were not notified of and had not been referred to the Local Authority.” from the report
Some risk records were inconsistent
needs fixingInspectors found inconsistencies in records used to monitor pressure relief and catheter care. Management had put an improvement plan in place.
“We did find some inconsistencies in some recordings to monitor risk around pressure relief and catheter care.” from the report
Caring rating fell
minorThe Caring rating changed from Outstanding to Good. The report still found kind and respectful care, but families may want to understand the reason for the change.
“At this inspection this key question has now deteriorated to Good.” from the report
- 01What checks now make sure every safeguarding incident is reported to CQC and referred to the local authority without delay?
- 02What has changed to improve the recording of pressure relief and catheter care?
- 03Why did the Caring rating fall from Outstanding to Good, and what improvements have been made since the inspection?
- 04How do you monitor falls and staffing levels on the memory care floor?
- 05How are each person's activity preferences and end of life wishes kept up to date and shared with staff?
This was a planned, unannounced inspection covering all five CQC questions, and it looked at both the premises and the care provided. This explanation was written from the published report of 16 November 2019 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 Bishops Manor
Each visit the CQC has published, newest first, back to the day the home was registered.
- February 2022Inspected but not ratedcurrent ratingSafe: Inspected but not rated
- November 2019GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2017
Registered with the Care Quality Commission on 21 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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