CQC report explained · a residential care home
What the CQC found at Bournville Grange Limited
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Risks, staffing, medicines and emergency arrangements were managed safely, although some areas needed a deep clean.
- Effective?
- Good
- People received support that met their health, nutrition and personal needs. Staff understood consent and mental capacity requirements and people had access to healthcare.
- Caring?
- Good
- People were treated with kindness, dignity and respect. Staff knew people well, involved them in decisions and supported their independence.
- Responsive?
- Good
- Care and support were personalised and activities reflected people's interests. Some care plan information was contradictory, but a new checking system had started to identify and correct errors.
- Well-led?
- Requires improvement
- Managers were approachable and had quality checks in place. However, these systems were not yet fully embedded, and not all care plans had been checked.
What inspectors found, April 2019
Rated Good overall; inspectors found safe, kind and responsive care, but leadership and quality checks still required improvement.
The inspection was unannounced and took place on 5 March 2019. Two inspectors and an expert by experience spoke with people living at the home, relatives, staff and managers. They also observed care and checked care plans, medicines records, recruitment, training and quality monitoring.
People were found to be safe. Staff understood safeguarding, risks and emergency procedures. Medicines were managed safely, although some areas needed a deeper clean. People received effective care, including support with food, drink, healthcare and their legal rights.
People were treated with kindness and respect. Their choices, independence, activities and communication needs were supported. Care plans were generally useful, but some information was contradictory and not all plans had yet been checked.
The overall rating was Good. Safe, Effective, Caring and Responsive were all rated Good. Well-led was rated Requires Improvement because the provider needed to make quality systems part of the home's everyday culture and show that improvements would last.
Safe medicines support
Trained staff supported people with their medicines safely. Records, storage and stock checks were in place.
“People received safe support with their medicines by competent staff members.” from the report
Kind and respectful staff
Inspectors saw positive relationships and compassionate support, including when a person was distressed.
“People were supported and treated with dignity and respect; and involved as partners in their care.” from the report
Personalised activities
People took part in activities based on their interests and preferences, including games, crafts and construction activities.
“People took part in activities that they enjoyed, found interesting and stimulating.” from the report
Access to healthcare
The home arranged healthcare support promptly when needed and followed professional advice.
“People had access to healthcare services when they needed it.” from the report
Quality systems were not fully embedded
needs fixingThe provider had regular checks, but inspectors wanted stronger evidence that improvements would last. This followed areas needing improvement at the previous four inspections.
“These systems needed further embedding into the practice and culture at Bournville Grange.” from the report
Some care plans contained conflicting information
needs fixingOne care plan recorded a person's preferred name differently in different sections. A new checking process had started, but it had not yet been completed for everyone.
“Although people's care plans considered all aspects of their individual circumstances; their dietary, social, personal care and health needs, some of the information was contradictory.” from the report
Some areas needed a deeper clean
minorInfection control systems were in place, but inspectors found that some parts of the home needed more detailed cleaning.
“However, some areas of Bournville Grange needed a "deep clean" which the registered manager was in the process of arranging at this inspection.” from the report
- 01Have all care plans now been checked for contradictory or inaccurate information?
- 02What checks are now used to make sure improvements are sustained between inspections?
- 03Has the deep cleaning identified in the report been completed, and how is cleaning quality monitored?
- 04How are families involved when care plans are reviewed or people's needs change?
- 05What has changed since the previous four inspections that shows the service is now consistently well-led?
This was a planned, unannounced inspection that looked at the premises and care provided across all five CQC questions. This explanation was written from the published report of 3 April 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, February 2018
Rated Requires Improvement; inspectors found progress in staffing, training and medicines, but serious gaps remained in risk management, care planning and quality checks.
This was an unannounced inspection on 17 and 18 October 2017. Inspectors met everyone living at the home, spoke with six people, four relatives, staff and a healthcare professional, and reviewed care records, staff files, incidents and quality checks.
The home had made improvements since April 2017. Staff recruitment, induction and training had improved. Medicines were managed safely, people had access to healthcare, and many staff interactions were kind. People also had activities and could raise concerns.
However, risks were not always properly assessed or managed. Inspectors found unsafe arrangements for two people at risk of choking or aspiration, missing care plans for a newly admitted person, and poor support at some mealtimes. Quality monitoring had not reliably found or fixed these problems. All five areas were rated Requires Improvement.
Improved staff training
The home had introduced a new induction programme and staff had completed more training, including medicines, moving and handling, first aid and safeguarding.
“There has been a lot in the last six months. It has been more in-depth.” from the report
Medicines management
Inspectors found that medicines were securely stored, given as prescribed and checked through audits. Staff competency checks had also been introduced.
“People received their medicines safely and as prescribed.” from the report
Staffing and recruitment
Inspectors found enough staff to meet people's needs at the time of the visit. Recruitment checks, including identity, references and DBS checks, had improved.
“We saw that staff were available to support people when needed and our discussions with staff confirmed this.” from the report
Activities and relationships
People could take part in activities based on their interests, including trips and group activities. Relatives were welcome to visit and were encouraged to share their views.
“People had access to activities they enjoyed.” from the report
Respect for independence
People were usually encouraged to make choices and retain their independence. Staff could describe ways to protect privacy and dignity.
“People were supported to retain their independence wherever possible.” from the report
Choking and aspiration risks
seriousFood did not always match people's assessed needs. One person was offered food that was not fork mashable, and another was given bread with the crusts still attached despite a recorded aspiration risk.
“This meant people were potential at risk of choking or aspiration and this was an issue that had also been identified at our inspection in April 2017.” from the report
Missing admission information
seriousA newly admitted person had no care plan at the time of the inspection, and their assessment did not contain enough reliable information. The person was later identified as needing nursing care.
“The admission process had not ensured people could be confident the service was suitable to meet their needs.” from the report
Mealtime support
needs fixingOne staff member tried to help two people eat at the same time. Staff did not always position people comfortably or sit with them while providing support.
“This did not ensure that the individuals concerned had the full attention of the staff member and also impacted on the person who did not require assistance.” from the report
Weak quality checks
seriousThe home's audits did not identify several problems, including incomplete assessments, unsuitable food textures and the lack of accident analysis. The provider was often reacting to problems rather than finding them through its own checks.
“The lack of effective systems to manage risks and to monitor and improve the quality and safety of the service is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.” from the report
Management arrangements
needs fixingThe previous registered manager had left, and the new manager had not yet registered. Formal supervision had not taken place since the previous manager left, and some notifications were delayed.
“There was no registered manager in post.” from the report
- 01How do you now check that each new resident's needs can be safely met before admission?
- 02How are choking, aspiration and food-texture risks recorded and checked at every meal?
- 03What action has been taken to make sure every resident has a complete, up-to-date care plan?
- 04How do you analyse accidents and incidents for patterns and make sure preventative action is taken?
- 05Has the new manager completed their application to become registered, and how are staff supervision and quality checks being maintained?
This was an unannounced inspection covering all five CQC questions and checking progress against the provider's action plan from the April 2017 inspection. This explanation was written from the published report of 20 February 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 Bournville Grange Limited
5 rated inspections over 3 years: the service has improved, from Requires improvement to Good.
- April 2019Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- February 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- June 2017Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2016Requires improvementstayed Requires improvementSafe: GoodEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- November 2015Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- October 2013
Report published without a new overall rating.
- April 2013
Report published without a new overall rating.
- October 2012
Report published without a new overall rating.
- December 2011
Report published without a new overall rating.
- January 2011
Registered with the Care Quality Commission on 18 January 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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