CQC report explained · a nursing home
What the CQC found at Bowerfield House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, April 2022
Bowerfield House rated Requires Improvement; inspectors found unsafe medicines and infection-control gaps, plus weak oversight.
This was an unannounced inspection after concerns were received, particularly about infection prevention and control. Inspectors visited the home on two days, reviewed documents remotely and spoke with people, relatives and staff. They looked closely at Safe and Well-led.
Medicines were not always recorded or stored safely. Infection-control procedures were not always followed, and some cleaning and vaccination records were incomplete. Staffing levels were judged adequate, but the home relied heavily on agency staff. Risk assessments were in place and people were protected from abuse.
The home had a new manager but no registered manager. Audits and records were not reliable enough, and the report found breaches of Regulations 12 and 17. The overall rating fell from Good at the previous inspection in June 2021 to Requires Improvement. The other key-question ratings were carried forward from the previous inspection.
Safeguarding and risk checks
People were protected from abuse, and care plans included appropriate risk assessments.
“People's care plans contained appropriate risk assessments and any environmental concerns had also been risk assessed.” from the report
Recruitment and staffing
Inspectors found safe recruitment processes and enough staff were deployed to keep people safe, although agency use was high.
“Staffing levels were adequate and recruitment processes were safe.” from the report
Infection-control supplies
The home had suitable personal protective equipment and regular testing was taking place.
“The home had good stocks of appropriate PPE and staff and people were regularly being tested.” from the report
Positive staff culture
Staff spoke positively about their work and about the new manager, who was trying to improve the home.
“Staff told us they enjoyed their roles. Feedback about the new manager was positive.” from the report
Medicines records and storage
seriousMedicine stock did not always match the records. Staff did not always record administration or exact doses, and fridge temperatures were not always recorded. This created a risk of harm, including potential overdose.
“We found medication was being administered and MARs were not being completed and this lack of recording could lead to a potential overdose.” from the report
Infection prevention
seriousSome infection-control procedures were not in place or were not followed. There were gaps in cleaning records, communal toiletries were left in bathrooms and some staff training had expired.
“The provider had failed to ensure appropriate processes were being followed regarding IPC practices.” from the report
Governance and records
seriousAudits did not always identify problems or happen as often as required. Records about care, staff and management were sometimes incomplete, unclear or out of date.
“Various documents in relation to people's care, staff records and management of the service were either not up to date or not easy to understand.” from the report
Staff training and agency use
needs fixingThe home was still working to improve infection-control and fire-training compliance. Staff and relatives also raised concerns about the high use of agency staff.
“there has been mega staff shortage and a lot of agency staff to top it up.” from the report
- 01What checks now confirm that medicine stock, administration records, exact doses and fridge temperatures are correct?
- 02How are you checking that infection-control procedures, cleaning records and visitor vaccination records are completed every time?
- 03What is the current level of agency staffing, and what are you doing to provide a more consistent staff team?
- 04What regular audits are now in place, and how do you check that they identify and fix problems?
- 05When will the manager be registered with the CQC, and how are fire and infection-control training gaps being addressed?
This was a focused inspection of Safe and Well-led after targeted concerns; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 5 April 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.
What inspectors found, June 2021
Rated Good; inspectors found safe, person-centred care and strong management, with staffing levels needing continued review.
This was an unannounced focused inspection on 9 and 10 June 2021. One inspector spoke with people, relatives and staff, observed care, checked the building and reviewed care, medicines, recruitment and management records.
The home was rated Good for Safe and Well-led. Inspectors found enough staff overall, safe medicines systems, good infection control, suitable risk assessments and staff who knew people well. They also found that managers investigated incidents, acted on feedback and supported staff development.
There were times when people in communal areas were left without staff present. Inspectors recommended that staffing levels continue to be reviewed closely. This inspection followed a Requires Improvement rating in April 2020, and the home was no longer in breach of regulations.
Staff knew people well
People were supported by a consistent staff team. Staff understood people's needs, preferences and routines.
“People were being supported by a consistent staff team who knew them well.” from the report
Safe care systems
Risk assessments and care plans guided staff. Medicines were safely stored, checked and managed.
“People were supported safely by staff and measures were in place to reduce potential risk where possible.” from the report
Good infection control
Inspectors were assured that the home followed infection control guidance, used protective equipment safely and supported visits in line with current guidance.
“We were assured that the provider was using PPE effectively and safely.” from the report
Open management
Managers investigated complaints, accidents and incidents, shared feedback with families and used audits and feedback to improve the service.
“The management team were committed to continued learning and improvement.” from the report
Staffing in communal areas
needs fixingAlthough staffing was generally enough, there were times when people in communal areas were left without staff present. Inspectors recommended that staffing levels continue to be reviewed using feedback, observations and information about people's needs.
“There were times where people in communal areas were left without staff being present which could place people at risk.” from the report
- 01How do you check that people in communal areas are supervised at all times when needed?
- 02What changes have you made to staffing levels since the inspection, and how do you review whether they are enough?
- 03How do you record and review falls, accidents and incidents, and how are families told what happened?
- 04How do you make sure care plans continue to reflect each person's needs, likes and preferences?
- 05What were the ratings for Effective, Caring and Responsive at the earlier comprehensive inspection?
This was a focused inspection of Safe and Well-led only; the other three key question ratings came from earlier comprehensive inspections. 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.
Every inspection of Bowerfield House
6 rated inspections over 6 years: the service has held its Requires improvement rating throughout.
- April 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- June 2021Goodup from Requires improvementSafe: GoodWell-led: Good
- April 2020Requires improvementdown from GoodSafe: Requires improvementWell-led: Good
- February 2018Goodup from InadequateSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- March 2017Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: InadequateWell-led: Inadequate
- March 2016Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 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.
- 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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What to check when you visit
At least 100 live-in carers within about an hour of Stockport
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.
“Primrose is a very kind and compassionate healthcare professional”
“She is an exemplary carer, she is knowledgable empathetic and very respectful in the home.”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.