Background to this inspection
Updated
22 April 2022
The inspection
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.
As part of this inspection we looked at the infection control and prevention measures in place. This included checking the provider was meeting COVID-19 vaccination requirements. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.
Inspection team
The inspection was carried out by two inspectors.
Service and service type
Bournedale House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
The service did not currently have a manager registered with the Care Quality Commission. We met with the manager, who had not yet applied to register with the Care Quality Commission. The registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.
Notice of inspection
This inspection was unannounced.
What we did before the inspection
We reviewed information we had received about the service. We sought feedback from the local authority and professionals who work with the service. The provider was not asked to complete a Provider Information Return (PIR) prior to this inspection. A PIR is information providers send us to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We spoke with two people who used the service about their experience of the care provided. We spoke with the manager, deputy manager and three members of care staff including night care staff and the cook.
After the inspection
We continued to seek clarification from the provider to validate evidence found. We looked at training data and quality assurance records. We spoke to three members of staff and three family members of people who use the service.
Updated
22 April 2022
About the service
Bournedale House is a residential care home providing personal care for up to 11 people who may be living with dementia. At the time of the inspection, nine people were living at the home.
People’s experience of using this service and what we found
We found significant concerns in relation to the infection prevention and control (IPC) practices within the service. People’s medicines were not always managed and administered safely. The provider had not adhered to safe recruitment practices. Staff told us they had not received any supervision or enough training to meet people’s individual needs. The provider did not have robust procedures and processes in place to protect people from the risk of abuse. Risk assessments had not always been completed in relation to known risks to people or plans developed for managing these risks
People’s needs and choices had not always been appropriately assessed before they moved into the home to ensure effective outcomes of their care. People were not always supported by staff who had the skills and knowledge to meet their needs. People’s individual dietary needs were not always addressed. People did not always have timely access to healthcare services and support. The physical environment had not been adapted to the needs to people living with dementia. The provider was not working in line with the principles of the Mental Capacity Act 2005.
People were not always well treated. People’s relatives expressed mixed views about how staff treated their loved ones. People’s independence was not always fully promoted. We were not assured staff had the time to listen to people and involve them in decisions.
People’s care plans were not person-centred to help staff ensure they received personalised care. They did not provide staff with clear guidance on how to meet people’s individual needs. People were not supported to follow their interests or take part in meaningful activities, and they showed signs of boredom. The provider did not have a complaints policy or systems to record or respond to complaints.
We were not assured the provider or manager understood regulatory requirements. The provider did not have effective quality assurance systems and processes in place. The provider had not established robust systems and processes to enable staff to record and report accidents or incidents. Records relating to people’s care were not always accurate. The provider had not actively sought the views of people, relatives, staff or visiting professionals on the service. We were not assured the provider or manager understood their responsibilities under the duty of candour.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
This service was registered with us on 21st January 2022 and this is the first inspection.
Why we inspected
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.
The inspection was prompted in part due to concerns received about infection control and medicines management. A decision was made for us to inspect and examine those risks.
We have found evidence that the provider needs to make improvements. Please see the Safe, Effective, Caring, Responsive and Well Led sections of this full report.
Enforcement and Recommendations
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.
We have identified breaches in relation to person centred care, safe care and treatment, safeguarding people from abuse and improper treatment, receiving and acting on complaints, good governance and staffing at this inspection.
Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.
Follow up
We will continue to monitor information we receive about the service, which will help inform when we next inspect.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.
For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.