CQC report explained · a residential care home
What the CQC found at Bon Secours
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found people were not always protected from avoidable harm. Shared staffing breached infection control guidance, some as-needed medicine authorisation records were unsuitable, and epilepsy care plans lacked important information.
- Effective?
- Good
- This question was not assessed during this focused inspection. Its previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not assessed during this focused inspection. People said they were happy and liked the staff.
- Responsive?
- Good
- This question was not assessed during this focused inspection. The report says care and support was personalised to people's needs and communication preferences.
- Well-led?
- Requires improvement
- Management systems did not reliably identify or deal with risks and regulatory duties. Five potential safeguarding incidents were reported late, and quality checks did not identify gaps in epilepsy guidance.
What inspectors found, June 2021
Bon Secours was rated Requires Improvement; inspectors found caring support but infection control and management systems were not reliable enough.
This was a focused inspection on 25 March 2021. One inspector reviewed records, medicines, recruitment and management systems, and spoke with two people and three staff members. The inspection looked mainly at Safe and Well-led.
People said they felt safe, were happy living at the home and liked the staff. The home was clean and tidy, had enough staff and generally provided personalised support. Medicines were stored and managed safely, although some records for as-needed medicines did not match the required process.
Inspectors found that staff were being shared between two homes, against current infection control guidance. They also found five safeguarding incidents had not been reported to CQC without delay, and that quality checks had not identified important gaps in epilepsy guidance.
The overall rating fell from Good to Requires Improvement. Safe and Well-led were both rated Requires Improvement. The other three question ratings were not reassessed during this focused inspection and previous ratings were used in calculating the overall result.
People felt safe and valued
People told inspectors they felt safe, were happy living at the home and liked the staff.
“People told us they felt safe, they were happy living at Bon Secours and liked the staff who supported them.” from the report
Personalised support
Support was tailored to people's needs and communication preferences. The home helped people have choice, control and opportunities to become more independent.
“People received care and support personalised to their individual needs and suited to their communication preferences.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs. Recruitment checks, including DBS checks and references, had been completed.
“There were enough staff to meet people's needs and keep them safe.” from the report
Medicines generally managed safely
Medicines were stored safely, reviewed and prescribed as required. The main problem was with authorisation records for some as-needed medicines.
“Medicines were managed and stored safely. People's medicines were reviewed annually, or when their needs changed, to ensure they were still required and appropriate.” from the report
Shared staff and infection control
seriousStaff were shared between two homes despite current guidance saying this should not happen. Inspectors said this left people at risk of harm.
“Although the service had mitigation, such as lateral flow tests for shared staff before and after shifts, sharing of staff is in direct contravention of current published guidance.” from the report
Safeguarding incidents reported late
seriousFive potential safeguarding incidents were not reported to CQC without delay. This meant CQC could not oversee the events when they happened.
“The provider had failed to notify us at the time, on five occasions, of incidents of potential safeguarding matters.” from the report
Weak quality monitoring
seriousManagement checks did not identify important problems with notifications and epilepsy guidance. Inspectors found the provider's systems were not operating effectively.
“The provider had failed to establish and operate processes effectively to monitor and improve the quality of the service.” from the report
Epilepsy plans lacked detail
needs fixingTwo people's plans said when to call 999 but did not explain what their seizures might look like. Information was added after inspectors raised the issue.
“There was no detail of what their seizures looked like or how a person may present.” from the report
As-needed medicine records
needs fixingSome forms did not support the required authorisation process for as-needed medicines. The forms were revised immediately after the inspection.
“Examination of PRN administration records found the forms used to record authorisation did not support the process.” from the report
- 01How do you now prevent staff from being shared between this home and another location?
- 02How are safeguarding incidents reported to CQC and the local authority without delay?
- 03What changes have been made to epilepsy care plans, and how do you check that staff understand them?
- 04How do you check that as-needed medicine authorisations are recorded correctly?
- 05What evidence can you show that your quality monitoring systems now identify and address problems promptly?
This was a focused inspection of Safe and Well-led only; the other ratings carried over from the previous comprehensive inspection and were used in calculating the overall rating. This explanation was written from the published report of 25 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.
What inspectors found, March 2018
Rated Good; inspectors found safe, kind and person-centred care, with some improvements recommended to risk assessments and future planning.
This was an unannounced comprehensive inspection. The inspector met all three people living at the home, spoke with staff and the registered manager, observed care and checked records including one care plan, medicines records, audits and staff meeting minutes.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe recruitment, safe medicines systems and a clean, well-maintained home.
People were supported to make choices, stay independent and take part in work, college, hobbies and community activities. Staff were described as kind and respectful, and people were involved in their care and support plans.
The home remained Good, as at the previous inspection. Inspectors recommended clearer information in some risk assessments and more visual planning for personal goals. They also noted plans to discuss people's wishes if they became seriously unwell.
Choice and independence
People were supported to make decisions, take sensible risks and develop daily living skills. They could take part in cooking, cleaning, travel, work, college and community activities.
“People continued to lead the lives they wanted to, people were supported to meet friends, follow their hobbies and interests and to get a job if this is what they wanted.” from the report
Kind and respectful staff
Inspectors saw a relaxed relationship between people and staff. Staff knew people well and responded calmly when someone became anxious.
“There was a feeling of trust and mutual respect, there was laughter and joking and people seemed at ease with the staff and each other.” from the report
Staffing and medicines
There were at least two staff on duty, and sometimes three, to support the three people living at the home. Medicines records and storage were checked regularly.
“There was always at least two and sometimes three members of staff on duty to support the three people at the service.” from the report
Person-centred support
Support plans reflected people's individual needs, interests and preferences. People were involved in writing and reviewing their plans.
“People continued to contribute to their support and continued to receive person centred care that met their individual needs.” from the report
Learning and oversight
The registered manager and senior staff reviewed incidents, complaints and staff practice. Audits and external checks were used to identify and track improvements.
“Accidents, incidents and complaints were reviewed by the registered manager and by staff at the provider's head office to check if any patterns were emerging.” from the report
Risk assessments
needs fixingInspectors recommended adding the date of the most recent event to some risk assessments, such as the last seizure. This would help staff judge the risk more accurately.
“we recommended that the risk assessments include the last time the risk occurred.” from the report
Personal goals
needs fixingSome people's goals and hopes were recorded, but inspectors recommended making the plans more visual and naming who would help, with timescales for actions.
“we recommend that the provider helps people plan towards these goals more visually naming who will support people with timescales for actions.” from the report
Planning for serious illness
minorThe home had plans to discuss and record people's wishes if they became unwell, but these conversations had not yet happened.
“People had been supported through bereavement but had not yet been supported to talk about their wishes should they become ill and need support towards the end of their life.” from the report
- 01Have the risk assessments been updated to include the date of the most recent seizure or other relevant event?
- 02How are personal goals recorded now, including who will support each goal and when actions should happen?
- 03How will you help each person discuss and record their wishes if they become seriously unwell?
- 04How are people supported to take increasing control of their medicines safely?
- 05How do you check that staff continue to respond calmly and effectively when someone becomes anxious?
This was an unannounced comprehensive inspection covering all five rating areas; the report lists the visit as 31 January and 1 February 2018, although some sections refer to 2017. This explanation was written from the published report of 2 March 2018 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 Bon Secours
3 rated inspections over 6 years: the service has slipped, from Good to Requires improvement.
- June 2021Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- March 2018Goodstayed GoodSafe: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- August 2013
Report published without a new overall rating.
- November 2012
Report published without a new overall rating.
- June 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- December 2010
Registered with the Care Quality Commission on 30 December 2010.
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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