Archived: Bancroft Gardens Residential Home

Updated 8 October 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 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

Two inspectors and an Expert by Experience completed this inspection. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Bancroft Gardens Residential Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Bancroft Gardens Residential Home is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority, Healthwatch and other professionals who work with the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make.

We used all this information to plan our inspection.

During the inspection

We spoke with five people and eleven relatives about their experience of the care provided. We spoke with eight members of staff including three care workers, one senior care worker, the cook, the deputy manager and both partners from the provider. One of the partners was the registered manager. We also received feedback via email from one care worker.

We spoke to three healthcare professionals about their experience of the clinical care provided. 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 reviewed a range of records. This included multiple people’s care and medicine records. We looked at three staff files in relation to recruitment. A variety of records relating to the management of the service were also reviewed.

Updated 8 October 2022

About the service

Bancroft Gardens Residential Home is a residential care home providing accommodation and personal care to up to 16 people. At the time of our inspection there were 15 people using the service. Some of these people were living with dementia. The care home is situated in the centre of Stratford-Upon-Avon, overlooking the river.

People’s experience of using this service and what we found

Risk’s related to people’s health were not always identified, assessed or managed. Some people had recently lost weight. Records did not always evidence timely action had been taken to mitigate the risk of further weight loss.

Environmental risks were not always managed safely. There was an increased risk of falls from heights as bedrooms on the second floor either did not have a window restrictor or had a window restrictor that did not meet Health and Safety Executive standards. People could access the flat rooftop on the second floor as the key had been left in the lock. The security of the building was also compromised.

Fire risks were not always managed safely. An external agency had identified significant fire safety risks prior to our inspection. No action had been taken to reduce the identified risks.

Medicines were not always managed safely. Medicines were left unattended in the communal dining room on both days of our inspection and some medicines were not administered in line with best practice. Some people were prescribed medicines on an ‘as required’ to treat a short term or intermittent medical condition such as pain or anxiety. Some of these medicines were being administered by staff daily as a regular dose without an appropriate rationale.

There were enough staff to meet the providers assessed safe staffing numbers. However, the provider had experienced difficulties recruiting staff and as a result, staffing numbers were maintained by using temporary staff supplied through an agency. Relatives expressed concerns about the numbers of staff on shift. Required pre-employment checks had not always been completed. For example, one person was working without a valid Disclosure and Barring Service (DBS) check.

Some people did not receive care in a timely way because they were unable to summon assistance when care was needed. At various points throughout our inspection, people were calling out to receive care because they had been left without their call bell.

The quality of care provided to people at Bancroft Gardens Residential Home was inconsistent and we received mixed views from people and relatives. Some shared good experiences, whilst others did not. Whilst we saw some caring interactions between staff and people, staff had limited time to spend with people to enhance their well-being or to ensure effective communication. Some people commented staff did not always treat them with respect. People did not wish to elaborate on why they felt this way.

Basic assessments were in place to assess people’s mental capacity. However, these assessments were not decision specific and did not evidence how people had been supported and empowered to make specific decisions. People were not always supported to have maximum choice and control of their lives and staff did not always support people in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Infection control procedures were not always effective. Staff did not consistently follow current guidance when using personal protective equipment. There were limited risk management strategies to prevent infections entering the home. The home was clean, but there was no sluice facility available for disposal of clinical or bodily fluid waste. Bed rail covers were split and damaged which meant they could not be cleaned effectively. Some relatives told us there were often unpleasant odours when they visited.

The provider had not maintained effective oversight to ensure people received high quality care in a safe environment. We found widespread concerns in areas such as environmental risk management, risks to people’s health, medicines management, infection control, recruitment, mental capacity, accident and incident management and nutrition. Relatives recognised the commitment of the registered manager, but some did not feel the home continued to be well managed. Some relatives felt emotional responses from the registered manager prevented them from raising concerns.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 7 July 2018).

Why we inspected

The inspection was prompted in part due to concerns received about staffing, risk management and governance. A decision was made for us to inspect and examine those risks. 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.

We have found evidence that the provider needs to make improvement. The overall rating for the service is now inadequate based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

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 have identified breaches in relation to safe care and treatment, the premises, nutrition and governance at this inspection.

We met with the provider and the local authority following our inspection. The provider confirmed their intention to voluntarily close Bancroft Gardens Residential Home and cancel their registration. We will continue to monitor this closure and will take further action if needed.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety prior to the home closure. We will work alongside the provider and local authority to monitor progress of the home closure.

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.