CQC report explained · a nursing home
What the CQC found at Bispham Gardens
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Risks linked to pressure care, wounds and equipment were not always assessed or managed safely. Medicines, infection control, recruitment and safeguarding systems were otherwise described positively, although some medicines records needed improvement.
- Effective?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Caring?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Responsive?
- Good
- This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
- Well-led?
- Requires improvement
- Audits and checking systems had failed to identify or address important shortfalls. Staff were also unclear about who was responsible for some safety checks, although people, relatives and staff said the manager was approachable and listened.
What inspectors found, December 2023
Rated Requires Improvement; inspectors found unsafe risk management and weak checking systems, although staff were caring and infection control was good.
This was an unannounced focused inspection on 10 and 18 October 2023. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, checked medicines and records, and reviewed audits and training.
Inspectors found that risks were not always managed safely. Pressure care assessments and repositioning records were incomplete, some wound care could not be shown to have been followed, and some equipment was not fit for purpose or had not been fully risk assessed. These problems led to a breach of Regulation 12.
There were also positive findings. Medicines were generally managed safely, the home was clean, infection control was good, and people and relatives spoke positively about staff and management. The home was rated Requires Improvement for Safe and Well-led, and the overall rating changed from Good at the previous inspection.
Medicines were generally safe
Staff who administered medicines had training and competency checks. Inspectors observed medicines being given in line with best practice and found they were stored safely.
“Medicines were managed safely and properly.” from the report
Good infection control
Inspectors were assured about infection prevention, the use of protective equipment and the arrangements for visitors and infection outbreaks.
“We were assured that the provider was using PPE effectively and safely.” from the report
People felt safe and listened to
People and relatives gave positive feedback about safety, staff and the manager. The manager used meetings, surveys and staff feedback to hear people's views and act on them.
“The provider engaged with people who used the service and others acting on their behalf.” from the report
Learning from incidents
Accidents and incidents were reviewed for patterns and lessons were shared with staff to reduce the chance of similar events happening again.
“Staff recorded accidents and incidents, which the manager reviewed on a regular basis to identify any trends, themes and areas for improvement.” from the report
Pressure care and risk records
seriousOne person's pressure care risks were not assessed until six weeks after admission. Records also had significant gaps in repositioning, and staff could not show that another person's wound care plan had been followed.
“The management of risk was not always safe and some records related to people's care were not accurate and up to date.” from the report
Equipment checks
seriousSome mattresses were not fit for purpose and some equipment had not been fully risk assessed. Staff did not always follow plans for safe equipment use.
“We found a number of mattresses were not fit for purpose, despite being checked, and equipment that was in use without having been risk assessed thoroughly.” from the report
Audits did not lead to action
seriousThe home's own audits failed to identify some important problems, or did not ensure that known medicines-record issues were fixed. This was part of the breach relating to safe care and treatment.
“These had not all been operated effectively to identify and address the shortfalls we found during our inspection.” from the report
Unclear staff responsibilities
needs fixingStaff gave different answers about who was responsible for checking mattresses and repositioning records. Management said staff responsibilities were refreshed after the inspection.
“We found confusion among staff about their responsibilities.” from the report
Some medicines records incomplete
needs fixingGuidance for medicines given when needed and photographs in some medicines records needed improvement. These issues had been identified a month earlier but had not yet been fixed at the inspection.
“These shortfalls had been identified 1 month before but had still not been addressed at the time of our inspection.” from the report
- 01What has changed since the inspection to make sure pressure care risks are assessed promptly?
- 02How do you check that repositioning and wound care are carried out and recorded as planned?
- 03Which mattresses and other equipment have now been checked, and how are staff told to use them safely?
- 04Who is responsible for checking mattresses and repositioning records on each shift?
- 05Have the medicines guidance and missing photographs identified in the audit now been corrected?
This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings carried over from the previous inspection. This explanation was written from the published report of 20 December 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.
Every inspection of Bispham Gardens
2 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.
- December 2023Requires improvementcurrent ratingSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- April 2020GoodSafe: GoodWell-led: Good
- August 2023
Registered with the Care Quality Commission on 16 August 2023.
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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32 live-in carers within about an hour of Blackpool
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 £980 to £1,250 a week. 31 can care for a couple. 12 years' experience on average.
“Thanks to Tracy, Dad was always immaculately dressed and clean, his meals were all home cooked and nutritionally well balanced and his home was always kept really clean and tidy.”
“He developed a close affinity with Terence, spending time talking with him before he retired to bed and looking after his needs during the night.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.