CQC report explained · a residential care home
What the CQC found at Bowood Court & Mews
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- Risk assessments and care plans had improved, and staff took action to reduce identified risks. Medicines were administered safely, but records of some late medicines and controlled-drug checks were not always complete.
- Effective?
- Good
- People's needs were assessed and healthcare referrals were made when needed. Mealtime support was inconsistent on the day of inspection, although the provider acted on the feedback and found no evidence of weight loss.
- Caring?
- Good
- This key question was not inspected during this focused inspection. The previous rating was carried forward when calculating the overall rating.
- Responsive?
- Good
- This key question was not inspected during this focused inspection. The previous rating was carried forward when calculating the overall rating.
- Well-led?
- Requires improvement
- The service had improved its systems but they were not yet fully established or consistent. People and relatives were unclear about who was in charge, and some notifications to CQC were late.
What inspectors found, March 2024
Rated Good overall, but well-led Requires Improvement; inspectors found safer care after earlier breaches, with medicines records and management clarity still needing work.
This was an unannounced, focused inspection on 7 November 2023. Inspectors checked safe, effective and well-led care. They spoke with people, relatives, staff and a visiting professional, observed care, and reviewed care, medicines, staff and management records.
The home had improved since its previous inspection. Risk assessments and care plans were better, staff understood safeguarding, the home was clean, and people could access healthcare. Medicines were administered safely, but some records and controlled-drug checks were not consistently completed. The provider acted immediately on these issues.
Safe and effective were rated Good. Well-led remained Requires Improvement because management arrangements were unclear, some required notifications had not been made on time, and improvements still needed to be embedded. The provider was no longer in breach of the regulations identified at the previous inspection.
Personalised care planning
Care plans were detailed and reflected people's current needs, preferences and risks. Staff had guidance on how to provide person-centred care.
“Care plans were comprehensive, personalised and detailed people's current care needs and included how to safely manage any identified risks.” from the report
Safer risk management
The home had improved its approach to assessing and managing risks, including choking risks and modified meals.
“The provider had improved how they assessed risks to ensure people were safe. Staff took action to mitigate any identified risks.” from the report
Clean environment
Inspectors found the home clean, without unpleasant smells, and saw appropriate infection-control practices.
“The service was clean and odour free. The service had appropriate cleaning schedules in place.” from the report
Kind staff approach
Staff spoke kindly about the people they supported and showed commitment to providing good care.
“Staff we spoke with talked about people in a kind and compassionate manner and were passionate about providing good care.” from the report
Improved activities
Activities were being developed and inspectors saw people enjoying the newer activities.
“Activities were in the process of improvement and enrichment, and we observed people enjoying the new activities.” from the report
Medicines records and checks
needs fixingControlled-drug checks did not always follow the home's policy. Some medicines were given late without the reason being recorded, although inspectors found no impact on people and the provider acted during the inspection.
“Although we found no impact on people, improvements were needed in the record keeping of medicines and stock checks of controlled drugs.” from the report
Unclear management arrangements
needs fixingPeople and relatives were not always sure who was in charge. There had also been changes in managers, and some staff said management support and supervision were inconsistent.
“People and their relatives struggled to identify who was the manager in charge of running the service.” from the report
Inconsistent mealtime support
needs fixingOn one floor, some people did not appear to receive the support they needed to eat and drink enough. The provider introduced further checks and actions after inspectors raised this.
“On the day of our inspection, we observed some people were not supported to eat and drink enough to maintain a balanced diet.” from the report
Mixed views about staffing and food
minorFeedback from people and relatives varied about staffing, training and food. One person also said there was not enough choice in the meals.
“Feedback from people and observations regarding the lunch mealtime experience was mixed.” from the report
- 01Who is currently responsible for running the home, and how will families be told if this changes?
- 02How are controlled drugs now checked and recorded, and how do you make sure medicines given late have a documented reason?
- 03What has changed to make sure people receive the right support to eat and drink on every floor?
- 04What action has been taken to improve staff supervision, training and consistency?
- 05What can you tell us about the serious injury incident and any changes made to manage similar risks?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried forward to calculate the overall rating. This explanation was written from the published report of 28 March 2024 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, January 2023
Rated Requires Improvement; inspectors found risks to safety, consent and management that need fixing.
This was a focused inspection after concerns about medicines and how the home was managed. Inspectors visited on 17 and 18 October 2022. They spoke with people, relatives and staff, observed care, and checked care, medicine and management records.
The home was not always safe. Risks in the building were not consistently managed, medicines were not always handled safely, and some staff had not completed important training. People were also at risk from unclear care plans, unsafe restrictions and gaps in safeguarding.
Care was not always effective or centred on people's needs and wishes. Inspectors found weaknesses in mental capacity and consent processes, nutrition support, activities, care planning and staff supervision.
The overall rating changed from Good at the previous inspection to Requires Improvement. Safe, Effective and Well-led were all rated Requires Improvement. Caring and Responsive were not assessed in this focused inspection, so their previous ratings were used when calculating the overall rating.
Infection control
Inspectors were assured that the home had suitable arrangements for preventing and managing infections, including the use of protective equipment.
“We were assured that the provider was responding effectively to risks and signs of infection.” from the report
Some medicines guidance
Protocols were in place for some medicines given when needed. These included the maximum dose, reasons for use and how often they could be given.
“This meant staff had guidance on how and when to administer these medicines safely.” from the report
Staff effort
Although staffing concerns were raised, inspectors recorded that staff worked hard to support people.
“Staff worked hard to support people, but they told us they did not have time to sit with people and spend quality time with them.” from the report
Visitors
The home had a system that allowed people to receive visitors.
“The provider had a system in place to ensure people could receive visitors to the home.” from the report
Unsafe environment
seriousSeveral hazards had not been identified or controlled. These included open kitchen and laundry doors, exposed hot water pipes, unlocked sluice rooms, unsecured wardrobes and an unsuitable window restrictor.
“Hazards and risks around the home had not been identified and mitigated.” from the report
Medicines safety
seriousInspectors found concerns about covert medicines, storage and disposal. Staff also reported that long shifts affected their ability to concentrate during medicine rounds, and the provider was investigating missed medicines.
“Medicine management was not consistently safe.” from the report
Consent and restrictions
seriousThe home did not consistently follow mental capacity law. Some restrictions, including sensor mats, lacked the required assessment, consent or best-interest decision.
“This placed people at risk of being unlawfully deprived of their liberty.” from the report
Care plans and nutrition
needs fixingCare plans were not always personalised or updated. Support for people at risk of weight loss and choking was not consistently recorded or provided.
“People did not consistently have the support they needed to maintain a healthy diet.” from the report
Staff training and support
needs fixingSome staff had not received training in safeguarding, mental capacity, dementia awareness or moving and handling. Staff did not receive regular supervision.
“Staff had not consistently received supervision and adequate training to meet people's needs.” from the report
Weak management checks
seriousAudits and daily checks failed to identify several safety and care problems. The home did not have a registered manager in post at the time of inspection.
“Quality assurance processes were not effective.” from the report
- 01What has been done to make the kitchen and laundry doors, hot water pipes, sluice rooms, wardrobes and window safe?
- 02How are missed medicines, covert medicines, thickener storage and medicine disposal now checked?
- 03Which residents have sensor mats or other restrictions, and how have consent, capacity and best-interest decisions been recorded?
- 04How are staff training, supervision and safeguarding checks kept up to date, including for agency staff?
- 05Who is currently responsible for management while there is no registered manager, and what progress has been made against the CQC action plan?
This was a focused inspection of Safe, Effective and Well-led only; Caring and Responsive were not inspected and their previous ratings were carried over when calculating the overall rating. This explanation was written from the published report of 17 January 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.
Every inspection of Bowood Court & Mews
5 rated inspections over 7 years: the service has held its Good rating throughout.
- March 2024Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- January 2023Requires improvementdown from GoodSafe: Requires improvementEffective: Requires improvementWell-led: Requires improvement
- August 2019Goodup from Requires improvementSafe: GoodEffective: GoodWell-led: Good
- November 2018Requires improvementdown from GoodSafe: Requires improvementWell-led: Requires improvement
- July 2017GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015
Registered with the Care Quality Commission on 23 October 2015.
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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Most charge £980 to £1,260 a week. 85 can care for a couple. 9 years' experience on average.
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