CQC report explained · a nursing home
What the CQC found at Bowerfield Court
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- People did not always feel there were enough staff, and records showed some long waits for help. Medicines and infection control had improved, but some medicine information and care records were incomplete.
- Effective?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Caring?
- Good
- This key question was not inspected during this focused inspection. Its previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- People generally received care that reflected their preferences, had choices and could raise concerns. Care plans still contained some confusing or inconsistent information and were not always reviewed consistently.
- Well-led?
- Requires improvement
- The new managers were viewed positively, but oversight systems were not yet firmly established. Care records, recruitment records and staff training records still needed improvement.
What inspectors found, February 2023
Bowerfield Court is rated Requires Improvement; inspectors found kind care and some improvements, but staffing and management records were still not reliable enough.
This was an unannounced focused inspection on 19 and 26 January 2023. Inspectors spoke with people, relatives and staff, observed care, checked the building and reviewed care, medicines, recruitment, training and management records.
The home was rated Requires Improvement overall. Safe improved from Inadequate to Requires Improvement, and Responsive improved from Requires Improvement to Good. Well-led remained Requires Improvement.
People generally described staff as kind and caring, and inspectors found the home clean. However, people sometimes waited too long for help, records did not always show that care needs were met, and staffing and training records were not easy to oversee.
The new management team was making improvements, but these were not yet firmly established. The home remained in breach of regulations about staffing and good governance. Medicines were mostly managed safely, but the report recommends improving medicine records.
Kind interactions
People generally said staff were kind and caring. Inspectors observed positive interactions between staff and people living in the home.
“We observed positive and caring interactions between people and the staff supporting them.” from the report
Clean environment
The home was clean and free from odours during the inspection. Staff used protective equipment appropriately and cleaning records were maintained.
“Records of cleaning were being maintained and the home was clean and free from odour throughout our site visits.” from the report
Activities and communication
A new activity worker had started developing activities. The home also had resources to support communication, including translation and large-format written information.
“Resources were available to support communication between staff and the people they were supporting.” from the report
Staffing and waiting times
seriousPeople did not always receive help when needed, including timely pressure relief. Staffing was more difficult at some times, such as mealtimes, and this was a breach of Regulation 18.
“The provider had failed to ensure that enough staff were consistently deployed across the home to meet the needs of people.” from the report
Incomplete oversight and records
seriousCare records were inconsistent, recruitment information was split across systems, and mandatory training records were not complete. The provider remained in breach of Regulation 17.
“The provider had failed to ensure that systems for oversight were sufficiently embedded to ensure people were receiving good quality care.” from the report
Medicine information
needs fixingSome information needed for safe medicine administration was missing, including instructions for medicines given when needed and people's administration preferences. The CQC made a recommendation rather than recording a breach in this area.
“Protocols to tell staff when medicines prescribed 'when required' should be administered were missing from people's eMARs.” from the report
- 01How many staff are on duty at different times, especially at mealtimes, and how do you check that call bells are answered promptly?
- 02How do you make sure residents receive regular pressure relief and that this is recorded?
- 03What has been done to bring care plans up to date and make sure reviews show residents' involvement?
- 04How are staff recruitment checks and mandatory training now recorded and monitored?
- 05Have the missing 'when required' medicine protocols and residents' medicine preferences been added to the electronic records?
This was a focused inspection of Safe, Responsive and Well-led; Effective and Caring were not inspected and their previous ratings were carried forward. This explanation was written from the published report of 17 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, May 2022
Bowerfield Court was rated Requires Improvement, with Safe rated Inadequate; inspectors found serious medicines, staffing and governance problems.
This was an unannounced focused inspection. Inspectors visited the home, spoke with people, relatives and staff, observed medicines being given, checked records and reviewed medicines storage and recruitment files. The inspection took place because of concerns about medicines, staffing and care.
Inspectors found medicines were not always given, stored or recorded safely. There were also unsafe infection control processes, staff shortages, long waits for call bells and gaps in risk assessments and records. The home was clean and had plenty of protective equipment, but some infection control checks and records were missing or not followed.
The home was rated Requires Improvement overall. Safe was rated Inadequate, while Responsive and Well-led were rated Requires Improvement. The previous overall rating was Good in February 2019. The ratings for Effective and Caring were not reviewed during this focused inspection and carried over from the previous inspection.
Clean home and protective equipment
The home was clean and tidy during the visit and had good supplies of protective equipment. People and staff were regularly tested.
“The home had good stocks of appropriate PPE and staff and people were regularly being tested.” from the report
Safeguarding arrangements
The home had safeguarding policies and procedures. Staff said they had safeguarding training and could explain what they would report.
“Systems and processes were in place to safeguard people from the risk of abuse.” from the report
Communication support
Inspectors found that people's communication needs were being met. The manager described using picture cards and assistive technology where needed.
“People's communication needs were being met. Care plans had relative's communication logs in place.” from the report
Activities and visiting
An activities coordinator planned activities, and inspectors saw people taking part in a game and discussing International Women's Day. Visitors could book visits through a procedure intended to reduce infection risks.
“During our inspection we were able to see people taking part in a game of Jenga and also there were discussions around international women's day.” from the report
Medicines errors
seriousMedicines were missed, given incorrectly and not always recorded properly. Inspectors found risks involving diabetes medicine, insulin, paracetamol, thickener and medicine supplies.
“one person had missed a tablet for diabetes for nine days due to an error with the monthly medicine's changeover.” from the report
Infection control records
seriousSome infection control processes were not followed. Records about vaccinations, cleaning and hazardous substances were incomplete or out of date.
“There were various gaps and missing documentation in relation to cleaning records, though the home was clean and tidy on the day of our on-site inspection.” from the report
Poor governance and records
seriousImportant care, recruitment, staff and management records were not always accurate or current. Audits did not consistently lead to improvement.
“Various documents in relation to people's care, recruitment records, staff records and the management of the service were not up to date or accurate.” from the report
Care plans not always current
needs fixingCare plans contained information about people's health and backgrounds, but some were not updated. This could make it harder for staff to follow people's current needs.
“Care plans were in place containing information to guide staff about people's health conditions and backgrounds, however, these were not always upto date.” from the report
- 01What changes have been made to prevent missed, wrong or late medicines, and how are medicine audits now checked?
- 02How many staff are working on each shift, including agency staff, and how will you prevent long waits for call bells?
- 03What infection control records and checks are now in place for cleaning, vaccinations and hazardous substances?
- 04How are care plans, risk assessments and recruitment records being kept accurate and up to date?
- 05Who is currently responsible for managing the home, and what progress has been made with the registered manager application?
This was a focused inspection of Safe, Responsive and Well-led only; the Effective and Caring ratings carried over from the previous inspection. This explanation was written from the published report of 6 May 2022 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 Bowerfield Court
5 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- February 2023Requires improvementcurrent ratingstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2022Requires improvementSafe: InadequateResponsive: Requires improvementWell-led: Requires improvement
- April 2021Inspected but not ratedSafe: Inspected but not rated
- February 2019Goodup from Requires improvementSafe: GoodResponsive: GoodWell-led: Good
- June 2018Requires improvementstayed Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- September 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2014
Registered with the Care Quality Commission on 15 July 2014.
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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These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £980 to £1,260 a week. 88 can care for a couple. 10 years' experience on average.
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“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
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