CQC report explained · a nursing home
What the CQC found at Boldmere Court Care Home
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Some time-critical controlled medicines were not given at the prescribed time. One bedroom was unsafe, and risk assessments were not always detailed or up to date.
- Effective?
- Requires improvement
- Records about restraint and best-interest decisions did not contain enough detail. Handover information was sometimes incomplete, although people were supported with food, drink and healthcare.
- Caring?
- Good
- This key question was not inspected during this focused visit. The report says ratings for key questions not inspected were taken from the last inspection.
- Responsive?
- Good
- This key question was not inspected during this focused visit. The report says ratings for key questions not inspected were taken from the last inspection.
- Well-led?
- Requires improvement
- The provider's audits did not identify problems with medicines, restraint records, best-interest records, handovers or bedroom safety. Staff and relatives nevertheless spoke positively about the management and support available.
What inspectors found, February 2023
Boldmere Court Care Home is rated Requires Improvement; inspectors found kind care and enough staff, but important safety, consent and management checks were not reliable.
This was an unannounced focused inspection on 14 and 21 November 2022. Inspectors reviewed Safe, Effective and Well-led. They spoke with people, relatives and staff, and checked care, medicines, restraint and management records.
The home had enough staff and people said they felt safe. Staff were trained and knew how to report abuse. However, some medicines were late, one bedroom was unsafe, and risk assessments did not always give staff enough current information.
Records about restraint and best-interest decisions were not detailed enough. Handover information was sometimes incomplete. The provider's audits had not found several of these problems. The overall rating was Requires Improvement, and the Safe, Effective and Well-led ratings all remained Requires Improvement.
Safeguarding
People and relatives said staff helped keep people safe. Staff had safeguarding training and knew how to report abuse or concerns.
“The provider had safeguarding systems in place and staff had a good understanding of what to do to make sure people were protected from avoidable harm or abuse.” from the report
Staffing and training
Inspectors found enough staff on duty. New staff received induction and staff said training and support were good.
“There were sufficient numbers of staff on duty to meet people's needs.” from the report
Food and healthcare
People had access to food and drink and were supported with their nutrition and hydration. The home worked with health professionals and updated care plans when advice changed.
“People had choice and access to sufficient food and drink throughout the day, food was well presented, and people told us they enjoyed it.” from the report
Positive staff culture
Staff said they felt valued and able to raise concerns. Relatives and people also spoke positively about the care and management.
“Staff were positive about the provider's training programme.” from the report
Late medicines
seriousSome people did not receive time-critical controlled medicines at the prescribed time. The report says no one was harmed, but this was a breach of safe care and treatment.
“Some people received time-critical controlled medication however they did not always receive their medication at the required prescribed time.” from the report
Unsafe bedroom
seriousOne person's bedroom contained a broken wardrobe with loose handles and drawers. The report said this placed the person and others at risk of harm.
“One of the wardrobes was broken, with handles and drawers hanging from the structure.” from the report
Weak quality checks
seriousThe provider's audits failed to find several problems identified by inspectors. This meant the systems did not reliably show that safety was being managed.
“Systems and processes were not robust enough to demonstrate safety was effectively managed. This placed people at risk of harm.” from the report
- 01What changes have been made to ensure time-critical medicines are given at the prescribed time?
- 02How are bedroom safety checks carried out, and has the unsafe bedroom issue been fully resolved?
- 03How do you record and review restraint, including de-escalation attempts, triggers and the length of time restraint is used?
- 04How are best-interest decisions and stairgate restrictions recorded and reviewed?
- 05What has changed in the audit system so that problems with medicines, handovers, care records and safety are found promptly?
This was an unannounced focused inspection of Safe, Effective and Well-led; the report says ratings for key questions not inspected were carried over from the last inspection. This explanation was written from the published report of 24 February 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.
What inspectors found, June 2021
Boldmere Court Care Home is rated Requires Improvement; inspectors found concerns about restraint records, risk guidance and quality checks, although staffing, medicines and communication were positive.
This was an unannounced inspection prompted partly by concerns about safeguarding and restraint. Two inspectors and a nurse specialist visited on 28 April 2021, then contacted relatives and staff by telephone from 2 to 3 May.
Inspectors found that some people were not supported in the least restrictive way or fully in their best interests. Records about restraint were not clear enough, and care plans did not always give staff consistent guidance about risks and behaviour.
The home had enough staff, medicines were managed safely, and relatives reported good communication. However, infection control checks, dementia-friendly surroundings and wider quality monitoring did not always identify problems.
The overall rating fell from Good at the previous inspection, published in August 2018, to Requires Improvement. Safe, Effective and Well-led were each rated Requires Improvement. Caring and Responsive were not inspected at this visit, so earlier ratings for those areas were carried forward.
Enough staff
Inspectors saw staff respond to requests promptly, and staff and relatives said there were enough staff to keep people safe.
“Staff and relatives told us there were enough staff to keep people safe.” from the report
Medicines
Medicines were stored and given safely. Guidance was available for medicines given only when needed.
“Medicines were managed safely. We saw medicines had been stored safely and records indicated people had received their medicine as required.” from the report
Healthcare support
The home worked with healthcare professionals, including the GP practice and tissue viability nurses, to support people's health.
“Records showed healthcare professionals had been contacted in support of people's health.” from the report
Communication with relatives
Relatives spoke positively about communication and felt supported with visiting during the pandemic.
“Relatives we spoke with felt engaged with the home and said there had been good communication during the COVID-19 pandemic.” from the report
Use of restraint
seriousRecords did not clearly show that restraint was the least restrictive option for the shortest possible time. Staff feedback about reviews and debriefs was inconsistent.
“The provider did not ensure restraint was implemented safely” from the report
Risk guidance
needs fixingCare plans and behaviour charts did not always contain enough information for staff to respond consistently and safely.
“This inspection found that people's care plans did not consistently reflect their current risks and provide consistent guidance to staff to keep people safe.” from the report
Quality checks
needs fixingAudits and monitoring systems missed problems relating to restraint, behaviour records, PPE and the environment.
“The provider's systems to monitor and improve the quality of the services were not always effective in identifying areas requiring improvement and ensuring action was taken in a timely way.” from the report
PPE checks
needs fixingSome care staff wore PPE that had not been supplied by the provider, so inspectors could not be sure it met the required standard. The manager addressed this after the inspection.
“We observed some care staff wearing PPE that had not been supplied by the provider, therefore we could not be assured it met the standards required by the Government's COVID19 guidance.” from the report
Dementia-friendly surroundings
minorSome surroundings needed improvement, including unclear clocks and a room without personalisation. The provider took immediate action on the examples discussed.
“In one lounge we saw two clocks were in place, both of which were difficult to read, and which were showing different times.” from the report
- 01What changes have been made to restraint recording, review and debriefing since the inspection?
- 02How are staff trained to support people whose behaviour may challenge others, and how is this training checked?
- 03Have all residents' behaviour plans and risk assessments been updated, and how do you make sure staff follow them consistently?
- 04How do your audits now identify problems with safeguarding, PPE and dementia-friendly surroundings?
- 05What progress has been made on the action plan requested by CQC for the Regulation 13 breach?
This was an unannounced, focused inspection prompted by safeguarding and restraint concerns; Safe, Effective and Well-led were inspected, while Caring and Responsive were not inspected and their previous ratings carried over. This explanation was written from the published report of 3 June 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 Boldmere Court Care Home
7 rated inspections over 8 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2021Requires improvementSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- November 2020Inspected but not ratedSafe: Inspected but not rated
- August 2018Goodstayed GoodSafe: GoodEffective: GoodWell-led: Good
- February 2017Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2015Requires improvementstayed Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- March 2015Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- March 2014
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- March 2012
Report published without a new overall rating.
- November 2011
Registered with the Care Quality Commission on 24 November 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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