CQC report explained · a residential care home
What the CQC found at Bourne Hill Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People's risks were assessed and care plans explained how staff should reduce them. Inspectors found safe medicines systems, enough staff, safe recruitment and appropriate building safety checks.
- Effective?
- Good
- Staff received induction, training, supervision and appraisals. People were supported with food, health appointments, communication and choices, including under the Mental Capacity Act.
- Caring?
- Good
- Staff treated people with kindness, dignity and respect. People were supported to make choices, maintain independence and be involved in decisions about their care.
- Responsive?
- Good
- Care plans were detailed, personalised and reviewed regularly. The home supported communication, relationships and community activities, but inspectors found that activities did not always reflect people's individual interests.
- Well-led?
- Good
- Managers had systems to check care quality, medicines, safety and care planning. The home used action plans and feedback to identify and make improvements.
What inspectors found, October 2019
Rated Good; inspectors found kind, safe and person-centred care, with activities needing to better reflect people's interests.
The inspection was unannounced and took place on 11 September 2019. One inspector spoke with people, relatives, staff, managers and a health professional. They also checked care records, medicines, staff files, risk assessments and quality checks.
The home was rated Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found people were treated with kindness and respect. Staff knew people's needs, communication methods and risks. Medicines, staffing, recruitment and safety checks were managed appropriately.
The home had improved since its previous Requires Improvement rating in 2018. The earlier breaches about risk management, staff support and management oversight had been addressed. Inspectors made a recommendation because activities did not always reflect people's hobbies and interests.
Kind and respectful care
Inspectors observed caring interactions and found that people appeared comfortable with staff. Relatives also spoke positively about the care and safety provided.
“We observed throughout the inspection that people were supported by staff who were kind, caring and respectful in their approach.” from the report
Personalised support
Care plans contained detailed information about people's needs, preferences, communication and behaviour. Staff knew people well and used this knowledge to support them.
“Care plans were person centred and gave detailed information about the person, their background, their needs, likes and dislikes, behavioural traits and how they wished to be supported.” from the report
Improved safety
Risk assessments had become comprehensive and person-centred. Medicines records were complete, and staffing and recruitment arrangements were suitable.
“People's risks associated with their health and care needs had been assessed to keep people safe and free from avoidable harm.” from the report
Improvement since the last inspection
The provider had addressed the earlier problems with risk management, staff support and quality monitoring. The home was no longer in breach of regulations.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Choice and independence
People were supported to choose how they spent their day, what they ate and drank, and how much help they wanted. Staff also encouraged independence in daily tasks.
“We observed people making decisions and choices about how they wanted to spend their day, what they wanted to eat and drink and the level of support they wanted from care staff.” from the report
Activities were not always individual enough
needs fixingInspectors found that activities did not always take account of each person's hobbies and interests. They recommended a more creative and person-centred approach.
“However, we did note that not everyone had access to activities which took into consideration their hobbies and interests.” from the report
- 01How will you make sure activities are based on each person's hobbies and interests?
- 02How do you review whether activities are varied and meaningful for each person?
- 03How will you involve my relative and our family in planning and reviewing their care?
- 04What detailed end of life wishes would you record if my relative's needs changed?
- 05How do you use audits and action plans to check that improvements are maintained?
This was an unannounced planned inspection covering all five CQC questions, the building and the care provided; nobody was receiving end of life care at the time. This explanation was written from the published report of 22 October 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.
What inspectors found, September 2018
Requires Improvement; inspectors found kind and responsive care, but risk records, staff support and quality checks were not reliable enough.
Inspectors visited on 29 August 2018. The visit was announced 24 hours in advance. They spoke with people using the home, staff and a relative, and checked care files, staff records, medicines, finances, training and quality checks.
People were described as safe, well treated and supported by caring staff. Medicines were administered safely, staffing levels met people's needs, the home was clean, and people had choices, activities and access to health care.
The home did not always update risk assessments when people's needs changed. Staff did not consistently receive formal supervision or appraisals, and some staff did not understand the Mental Capacity Act and Deprivation of Liberty Safeguards well enough. Quality checks had not found these problems.
The overall rating was Requires Improvement. Caring and Responsive were rated Good. Safe, Effective and Well-led were rated Requires Improvement. The home had been rated Good at the previous inspection in July 2017, and the earlier problem with notifying the CQC had been addressed.
Kind and respectful care
People and a relative described staff as caring. Inspectors saw staff spending time with people and supporting their privacy, dignity and independence.
“People and a relative told us the staff were caring.” from the report
Safe medicines handling
Medicines were stored securely, records were completed and checked, and staff handling medicines had received training.
“Medicines were recorded and administered safely.” from the report
Activities and personal choice
People had activities suited to their interests, including music, puzzles, arts and crafts, college, day centres, walks and shopping.
“People had access to planned activities.” from the report
Health and food support
People were supported with meals, drinks and specialist diets. They also accessed health professionals when needed.
“People were supported to maintain good health and to access healthcare services when required.” from the report
Risk assessments were incomplete
seriousOne person's care records did not contain risk assessments, and another person's assessment had not been updated after their behaviour became more challenging. This could leave staff without clear instructions to reduce risks.
“Risk assessments did not always accurately identify the risk and were not always updated when people's needs changed.” from the report
Staff support was inconsistent
seriousStaff did not always receive the formal supervision required by the home's policy. Inspectors also found that annual appraisals were not initially available and some staff lacked a good understanding of legal safeguards.
“Staff did not receive regular supervision and appraisals.” from the report
Quality checks missed problems
seriousThe home had regular monitoring systems, but these did not identify concerns about risk records, staff supervision, training and care plan reviews. This was a breach of the good governance regulation.
“Quality assurance checks were not always identifying problems with the service provision.” from the report
Some records needed updating
needs fixingFinancial risk assessments were supplied after the inspection. Water temperature checks were also not being recorded at the time of the visit.
“However, water temperature checks were not being recorded.” from the report
- 01How are risk assessments checked and updated when a person's needs or behaviour changes?
- 02How often does each member of staff receive supervision and an appraisal, and how is this recorded?
- 03What extra training have staff received on the Mental Capacity Act and Deprivation of Liberty Safeguards?
- 04How do your quality checks make sure they identify problems with risk assessments, care plan reviews and staff support?
- 05Are water temperature checks now recorded regularly, and can we see the records?
This was an announced inspection covering all five CQC questions, based on observations, discussions, records and information from professionals. This explanation was written from the published report of 20 September 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 Bourne Hill Care Home
4 rated inspections over 4 years: the service has held its Good rating throughout.
- October 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2018Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2017Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- June 2014
Report published without a new overall rating.
- April 2014
Report published without a new overall rating.
- November 2013
Report published without a new overall rating.
- January 2013
Report published without a new overall rating.
- January 2012
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 23 November 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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