CQC report explained · a nursing home
What the CQC found at Bourne Wood Manor Care Home
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Inspectors found people felt safe, staff understood risks and safeguarding, medicines were managed safely, and there were enough staff. Infection control and emergency evacuation arrangements were also found to be suitable.
- Effective?
- Good
- This area was not assessed during this focused inspection. The overall rating used ratings from the previous inspection for areas not inspected.
- Caring?
- Good
- This area was not assessed during this focused inspection. The overall rating used ratings from the previous inspection for areas not inspected.
- Responsive?
- Good
- This area was not assessed during this focused inspection. The overall rating used ratings from the previous inspection for areas not inspected.
- Well-led?
- Good
- Inspectors found a generally positive culture, clear management responsibilities, regular audits and plans to address issues. Feedback from healthcare professionals was mixed, particularly about communication and following instructions.
What inspectors found, September 2023
Rated Good; inspectors found people felt safe and well cared for, but communication with some healthcare professionals needed improvement.
This was an unannounced focused inspection on 27 July and 4 August 2023. Inspectors looked at whether the home was safe and well-led. They spoke with people, relatives, staff and healthcare professionals, observed care, and checked care records, medicines records, recruitment files and management records.
People and relatives said staff were kind and that they felt safe. Inspectors found enough staff, safe medicines arrangements, suitable risk assessments, emergency evacuation plans and effective infection control. Staff understood safeguarding, reporting concerns and how to respond to health deterioration.
The home was rated Good for Safe and Well-led. Some healthcare professionals reported problems with communication and staff not always following instructions. The provider had already identified this and had plans to improve it. The overall Good rating also used ratings from the previous inspection because this visit did not assess all five areas.
People felt safe
People and relatives said they felt safe and well looked after. Inspectors found staff understood safeguarding and knew how to report concerns.
“People and their relatives told us staff were kind and caring towards them and they felt safe living at Bourne Wood Manor Care Home.” from the report
Safe staffing
Inspectors saw enough staff during the visit, with people receiving help promptly. Agency staff were generally regular and received an induction before working independently.
“We observed there were sufficient staff deployed during the inspection. Staff attended to people in a timely manner and there were regular checks in place for people who preferred to stay in their rooms.” from the report
Medicines managed safely
Medicines were stored, recorded and given safely. Staff had training and checks to confirm their competence.
“People's medicines were received, stored and administered safely.” from the report
Learning from incidents
The manager reviewed accidents and incidents to look for patterns and reduce risks. The home had also made changes to improve how staff raised concerns with healthcare professionals.
“The registered manager monitored accidents and incidents to identify patterns and reduce the risk of them happening again.” from the report
Management systems
The home had clear responsibilities, regular audits and action plans when issues were found. People, relatives and staff were also invited to give feedback.
“There were systems in place to monitor the quality of the service and make improvements where shortfalls were identified.” from the report
Communication with healthcare professionals
needs fixingFeedback from healthcare professionals was mixed. Some said staff did not always follow their instructions, and the provider had identified a deterioration in these relationships and was taking action.
“Some healthcare professionals commented positively on the responsiveness of staff and others found staff did not always follow their instructions.” from the report
- 01What changes have you made to improve communication with visiting healthcare professionals?
- 02How do you check that staff follow healthcare professionals' instructions?
- 03What training has been arranged for people's specific needs?
- 04How will you use feedback from healthcare professionals and families to check that improvements are working?
- 05How do you make sure agency staff understand each person's risks and care needs?
This was a focused inspection of Safe and Well-led only; ratings for the other areas were carried over from the previous inspection when calculating the overall rating. This explanation was written from the published report of 13 September 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, November 2021
Bourne Wood Manor Care Home was rated Good; inspectors found people were safe and well supported, but staff had limited time for conversation and relatives wanted better communication.
This was an unannounced focused inspection on 27 October 2021. Inspectors looked only at Safe and Well-led because of concerns about staffing. They spoke with people, relatives, staff and health professionals, and checked care records, medicines records, staff files, rotas and management records.
The home was rated Good for Safe and Good for Well-led. Inspectors found that staffing levels were adequate, recruitment checks were strong, risks and medicines were managed safely, and infection control arrangements were effective. People and relatives said they felt safe and were happy with the care.
Inspectors did observe that staff were very busy and had limited time to sit and engage with people. Some relatives also wanted more regular updates. The manager made changes during and after the inspection to improve staff interaction and communication.
The overall rating stayed Good, as it had been at the previous inspection published on 1 February 2019. Effective, Caring and Responsive were not inspected during this visit, so those previous ratings were carried forward.
Good safety arrangements
Inspectors found that people's risks were understood and managed, while still supporting people to make choices and take positive risks.
“People's risks were understood and well managed, with a focus on positive risk taking.” from the report
Medicines and infection control
Medicines were checked and administered by trained staff. Inspectors were assured that infection prevention and control arrangements were effective.
“Medicines were well managed and infection control procedures were robust and effective.” from the report
Safe recruitment
The home carried out appropriate checks on permanent and agency staff and provided induction before staff worked without supervision.
“Staff were recruited safely and appropriate checks made to ensure that people had the right values and experience for the role.” from the report
Learning from incidents
The home reviewed accidents and falls, shared learning with staff and introduced a movement activity session after several falls.
“Accidents and incidents had been recorded in detail and lessons learned had been shared with the staff team to prevent them from reoccurring.” from the report
People involved in the home
People could contribute to decisions, suggest activities and take part in welcoming new residents and recruiting staff.
“People had been involved in the day to day decisions within the home.” from the report
Limited time for interaction
needs fixingAlthough staffing levels were judged adequate, inspectors saw that staff were very busy and did not have much time to sit and engage with people. Changes were made to staff distribution during the inspection.
“We observed staff were very busy on the day of inspection and did not appear to have sufficient time to sit with people.” from the report
Family communication
minorSome relatives wanted more regular updates from the home. The manager arranged a relatives' meeting and a newsletter after receiving this feedback.
“Some relatives we spoke with said they felt communication from the management needed improvement.” from the report
- 01How do you now organise staffing so people have enough time for conversation and activities as well as essential care?
- 02How often will my family receive updates, and who should we contact if communication is not working well?
- 03What checks and induction do agency staff receive before they support residents?
- 04What has the home learned from recent falls, and what results have you seen from the movement activity session?
- 05How will the key worker system keep my relative's needs and preferences known to staff and communicated to our family?
This was a focused inspection of Safe and Well-led only; Effective, Caring and Responsive were not inspected and their previous ratings were used in calculating the overall rating. This explanation was written from the published report of 25 November 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 Bourne Wood Manor Care Home
3 rated inspections over 5 years: the service has held its Good rating throughout.
- September 2023Goodcurrent ratingstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- November 2021GoodSafe: GoodWell-led: Good
- May 2021Inspected but not ratedSafe: Inspected but not rated
- February 2019GoodSafe: GoodWell-led: Good
- December 2017
Registered with the Care Quality Commission on 22 December 2017.
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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