CQC report explained · a residential care home
What the CQC found at Bluebell Residential Home Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- The visit looked only at infection control and selected safety issues, so the Safe rating was not reviewed. Inspectors found that staircase safety rails were fitted after the visit, while some records needed improvement.
- Effective?
- Good
- Does the care work? Training, consent, food and drink, working with GPs and nurses.
- Caring?
- Good
- Are people treated with kindness and dignity?
- Responsive?
- Good
- Is care built around the person? Care plans, activities, complaints.
- Well-led?
- Good
- Is the home run well? The manager, the culture, how problems get found and fixed.
What inspectors found, March 2021
Overall rating remained Good; this targeted inspection was not rated and found effective infection controls, but some safety and record-keeping issues.
Inspectors visited on 18 February 2021. They checked infection prevention and control measures, reviewed records, spoke with managers and walked around the home. This was a targeted inspection, not a full review of the service.
Inspectors were assured that the home had suitable infection control policies. Staff used protective equipment correctly, testing was in place, and checks were made on staff skills. The home also had arrangements for visitors, admissions, shielding, social distancing and managing outbreaks.
Inspectors found issues with the structure of the staircase. After the visit, safety rails were fitted to reduce the risk of harm. Records about checking visitors' health and what action to take during the pandemic needed strengthening.
The service was inspected but not rated at this visit. Its previous overall rating was Good, published in February 2019, and the report says that rating remained unchanged.
Infection control
Inspectors were assured that the home had arrangements to prevent and manage infections, including suitable policies and checks.
“We were assured that the provider was making sure infection outbreaks can be effectively prevented or managed.” from the report
Protective equipment and testing
Protective equipment was available and used safely. Testing was available for people living at the home and staff.
“We were assured that the provider was using PPE effectively and safely.” from the report
Staircase safety action
The home fitted safety rails after inspectors identified a staircase risk. This reduced the risk of harm.
“Since our inspection the registered manager has ensured safety rails have been fitted, to mitigate the risk of harm to people.” from the report
Staircase risk
seriousInspectors found issues with the structure of the staircase during their walkaround. Safety rails were fitted afterwards to reduce the risk of harm.
“We identified some issues in relation to the structure of the staircase.” from the report
Visitor health records
needs fixingRecords did not fully show that the health of visitors was being checked or that staff knew what signs to look for.
“Records required strengthening to ensure the registered manager assured themselves of the current health of any visitors, and that staff had information to know what to look for.” from the report
Pandemic response records
needs fixingWritten records could have been clearer about what action staff should take when caring for people during the pandemic.
“Records could also be improved about what action to take when caring for people living in the home during the pandemic.” from the report
- 01How have you checked that the new staircase safety rails are secure and effective?
- 02How do you now record and review the current health of visitors?
- 03What information do staff have about what signs to look for in visitors?
- 04What written instructions tell staff what action to take during an infection outbreak or pandemic?
- 05When will the next full inspection review all five key questions?
This was a targeted inspection of infection prevention and control and selected safety issues; it did not reassess the full Safe key question or the other ratings, which carried over from the previous inspection. This explanation was written from the published report of 24 March 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, February 2019
Rated Good; inspectors found kind, person-centred care, but some safety and care records needed correcting.
This was an unannounced inspection carried out on 20 November and 4 December 2018. Inspectors spoke with people living in the home, staff and a healthcare professional. They reviewed care records, medicine records and management records.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. People and relatives said they were happy with the care. Inspectors saw friendly staff who knew people well and supported their independence.
Some records were incomplete, inaccurate or lacked detail. These included records about risks, best-interest decisions, food and drink needs, and mobility. The home corrected these issues during or shortly after the inspection, and the report says they had no impact on people.
Kind, personal care
Staff built positive relationships with people and took time to understand their lives, hobbies and preferences.
“Staff took time to get to know people's preferences and used this knowledge to care for them in the way they liked.” from the report
Safe medicines support
Inspectors found that medicines were managed safely and records showed people received them as prescribed. Staff had training and competency checks.
“Medications were managed safely. Records confirmed people had received their medicines as prescribed.” from the report
Support for independence
People were encouraged to make choices and take positive risks where this helped them maintain independence and relationships.
“Staff knew what was important to people and supported them to take positive risk to maintain their independence.” from the report
Strong management oversight
The management team was present and knew people, their needs and relatives well. The home used quality checks and feedback to monitor the service.
“Systems and process were in place to oversee the service and governance systems drove improvements in the quality of the service.” from the report
Risk records were incomplete
needs fixingRecords used to monitor hydration, nutrition, pressure care and bed rail safety were not always completed or reviewed. The manager said this would be corrected straight away.
“the records used to monitor those risks such as hydration, nutrition, pressure care and bed rail safety were not completed or reviewed to provide information to staff on potential risk.” from the report
Mental Capacity Act knowledge
needs fixingStaff understanding of the Mental Capacity Act was limited. Further training was arranged, and evidence of completed best-interest meetings was provided after the inspection.
“Staff understanding of MCA was limited. The registered manager addressed this straight away and arranged further training for staff.” from the report
Some care plans needed correction
needs fixingSome care plans contained incorrect or incomplete information, including details about food and drink needs and whether a person could bear weight. These were corrected during the inspection.
“Some of the care plans we looked required further detail around people's specific needs.” from the report
- 01How are you now completing and reviewing records for hydration, nutrition, pressure care and bed rail safety?
- 02What extra Mental Capacity Act training have staff completed since the inspection?
- 03How do you make sure best-interest meetings and decisions are recorded?
- 04How do you check that care plans reflect changes in mobility, diet and other specific needs?
This was an unannounced planned inspection covering all five key questions, including both the care provided and the home environment. This explanation was written from the published report of 2 February 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 Bluebell Residential Home Limited
4 rated inspections over 4 years: the service has improved, from Requires improvement to Good.
- March 2021Inspected but not ratedcurrent ratingSafe: Inspected but not rated
Read what inspectors found at Bluebell Residential Home Limited →
- February 2019Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Bluebell Residential Home Limited →
- February 2017Goodstayed GoodSafe: Good
- June 2016Goodup from Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2015Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- January 2014
Report published without a new overall rating.
- August 2013
Report published without a new overall rating.
- May 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- September 2011
Report published without a new overall rating.
- March 2011
Registered with the Care Quality Commission on 23 March 2011.
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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