Bowerfield House

Bowerfield House is a nursing home providing accommodation for persons who require nursing or personal care and treatment of disease, disorder or injury for up to 26 people. At the time of the inspection 23 people were using the service. The nursing home accommodates people across two floors in one building.

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

Medicines were not managed safely, stock levels did not always match with records, medicines administration was not always being recorded and opened bottles of medicines and tubes of creams were not always dated when opened. The home was clean and tidy, though various infection prevention and control (IPC) practices and procedures were either not in place or not being followed. The manager implemented some of these processes during the inspection. Staff were safely recruited, and staffing levels were adequate, though the home did use a high level of agency staff. People were safeguarded from abuse and there were a variety of necessary risk assessments in place. The home was working towards improving their compliance rate for some training in areas including IPC and fire training.

There were some governance concerns in the home in relation to audits and gaps in paperwork. The service did not have a registered manager in post and there were only limited recent lessons learned documents in place. Staff spoke positively about the new manager and told us they enjoyed their roles. The manager told us they were working to improve and increase the number of meetings for people and their relatives. The service had recently sent surveys out to families and were awaiting their responses.

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 25 June 2021). At our last inspection we recommended the provider continues to review staffing levels. At this inspection we found the home had managed to keep a consistent level of staffing, though this was topped up by high use of agency staff.

Why we inspected

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about IPC. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with governance, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led. We looked at IPC 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 the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection. We have found evidence the provider needs to make improvements. Please see the safe and well-led sections of this report. You can see what action we have asked the provider to take at the end of this report. The provider has taken some immediate action to mitigate risk, however some improvements/actions will take time to embed.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bowerfield House on our website at www.cqc.org.uk.

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 will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to IPC, medicines management and governance at this inspection. Please see the action we have told the provider to take at the end of this report. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Bowerfield House is a residential care home providing personal and nursing care to 26 people at the time of the inspection. The service can support up to 26 people. Care is provided over two floors with shared communal areas including dining and lounge areas and a secure garden. All rooms are single occupancy, and some have en-suite facilities.

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

There were enough staff to meet the needs of people. We have made a recommendation about ongoing review of staffing levels. People were being supported by a consistent staff team who knew them well. Risk and needs were assessed, and staff took steps to reduce risk when possible and learn from when things had gone wrong. The home was clean and tidy and current guidance around good infection prevention and control, use of personal protective equipment and supporting visiting within the home was being followed.

The registered manager and management team were committed to learning and improvement. People, relatives and staff felt able to raise concerns with the registered manager and action was taken to investigate and address any issues. People’s feedback was requested and used to improve the service. Staff were encouraged to develop within their role.

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 requires improvement (published 06 April 2020). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We received concerns in relation to staffing and the management of falls. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We found no evidence during this inspection that people were at risk of avoidable harm from the concerns regarding staffing and the management of falls. Please see the safe and well led sections of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bowerfield House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Bowerfield House is a residential care home providing personal and nursing care to 23 people aged 65 and over at the time of the inspection. The service can support up to 26 people.

Care is provided over two floors with shared communal areas including dining and lounge areas and a secure garden. All rooms are single occupancy, and some have en-suite facilities.

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

There were not always enough staff to meet people’s needs. The registered manager had identified that staff deployment was an area for improvement and a new rota had recently been implemented and was subject to review. This change had reduced the number of falls experienced by people living at the service, but feedback we received was that there was still not always enough staff to meet people’s needs. People who were identified as being at risk of falls had risk assessments, and adaptations and equipment was put in place to reduce future risk. Information from accidents and incidents were analysed for themes and trends and action taken to address areas for improvement identified. Medicines were being safely stored and managed by staff who were trained and assessed as competent in this area. Staff were being safely recruited. Risk assessments were in place to reduce the risk to people from generic and specific areas of risk. We noted some areas of risk that required additional assessment and management during the inspection and these areas were immediately addressed

People’s needs were assessed prior to moving to Bowerfield House and the service supported people to access healthcare professionals as needed. People were receiving appropriate support with their diet and fluids needs and drinks and snacks were provided to people throughout the day. People told us the food was good. Staff received relevant training and support and felt confident in their job roles. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People were supported by kind and caring staff who knew them well. Staff respected people’s privacy and dignity and encouraged people to remain independent and make choices around their daily lives as much as possible. People were happy living at the home.

Staff understood people’s needs and work was ongoing to ensure that care plans were person centred. A range of activities were in place and people were encouraged and supported to engage in activities that were relevant to their interests. People and relatives knew how to make a complaint, felt confident to do so and these were investigated and responded to by the registered manager.

The registered manager was committed to driving improvement in the service and staff told us they felt involved and able to contribute to ongoing developments. There were a range of ways people could feedback into the service including surveys and meetings. However, not everyone was aware of when meetings were being held. Action plans were developed which included themes identified from feedback given, as well as accidents, incidents and complaints. Staff told us they felt clear about their roles and the provider had systems to ensure agency staff knew what was expected of them.

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 01 February 2018).

Why we inspected

The inspection was prompted in part by notification of a specific incident. Following which a person using the service sustained a serious injury. This incident is subject to an investigation. As a result, this inspection did not examine the circumstances of the incident. The information CQC received about the incident indicated concerns about the management of falls. This inspection examined those risks.

We have found evidence that the provider needs to make improvements and action is already being undertaken. Please see the safe section of this full report. You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified a breach in relation to Regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as there were not always enough staff to meet people’s needs. Please see the action we have told the provider to take at the end of this report.

We have also identified a potential breach of regulation 18 (notification of other incidents) of the Care Quality Commission (Registration) Regulations 2009 as the provider had not always sent required notifications to the Care Quality Commission in a timely way. We will follow our processes to consider an appropriate response to this outside of this inspection.

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. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We last inspected the service on 5, 6 and 8 December 2016 when we rated the service as inadequate. At that time we found the service was in breach of seven regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, these were in relation to person centred care, dignity and respect, need for consent, safe care and treatment, meeting nutritional and hydration needs, good governance and staffing. At that inspection we made one recommendation, which was in relation to how the provider handles informal complaints.

Due to the concerns we identified during that inspection, we wrote to the provider and requested they take a number of voluntary actions. This included ensuring all care plans and risk assessments be reviewed by the end of January 2017, reviewing staffing levels, assessing staff competence, keeping CQC informed about the recruitment of a suitable deputy and sending CQC an action plan. We requested the provider sent us evidence of the completed actions, and we would review this to inform our decision making as to whether any formal enforcement action was required. The provider agreed to take these actions.

This inspection was to check improvements had been made following the last inspection and to review the ratings.

Bowerfield House is a purpose built care home owned and operated by Maria Mallaband Group. The home provides nursing and personal care for up to 26 older people living with dementia. It is a two storey building situated adjacent to a larger sister home located on the same site. All bedrooms are single occupancy and some have en-suite facilities. There is a passenger lift providing access to the first floor, an enclosed garden area to the rear of the building and car parking is available within the grounds. At the time of our inspection there were 24 people living at Bowerfield House.

On entering the home we were met by the registered manager who was eager to show us the improvements they had made following the last inspection.

Systems to make sure the safekeeping and administration of medicines were followed and monitored were in place and reviewed regularly. Medicines were stored safely in locked clinic rooms and were administered by designated trained nurses. Any specific requirements or risks in relation to people taking particular medicines were clearly documented in their care records.

Risk assessments were in place for people who were at risk of falls and in relation to people’s skin integrity. Additional risk assessments were in place to meet people’s individual needs for example specific dietary requirements.

Staff we spoke with confirmed they had received safeguarding and whistleblowing training (raising a concern about a wrong doing in the workplace) and knew who to report concerns to if they suspected or witnessed abuse or poor practice. Records showed care workers received regular supervision to help make sure they were carrying out their duties safely and effectively.

Records in relation to the Mental Capacity Act 2005 were complete and up to date. Any restrictions were deemed to be in people’s best interest and the least restrictive.

People were supported by sufficient numbers of care workers and nurses. Staff we spoke with told us they had undergone a thorough recruitment process and undertaken employee induction and training appropriate to their job role. This helped to make sure the care and support provided was safe and responsive to meet peoples identified needs.

We saw people who required encouragement and prompting to eat and drink receive the required level of staff support at meal times. We saw staff offered people a choice of meals as displayed on the menu.

We saw positive and caring interactions between care workers, nurses and people who used the service, which helped to make sure their dignity and privacy was respected and their wellbeing was promoted.

End of life care procedures were person centred and aimed at supporting the person to have full control about decisions relating to their future care and end of life needs.

People lived in a clean and well maintained environment. Appropriate equipment and health and safety checks were carried out to help maintain a safe environment for people to live in.

People who used the service and their relatives were complimentary about the care and support provided and the attitude of the staff. They felt that the overall care provided was good.

Complaints were addressed and recorded appropriately. People’s relatives told us they knew how to make a complaint and felt confident to approach any member of the staff team if they had any concerns.

Accurate and complete records in respect of the care and treatment provided to people were being maintained. Systems were in place to monitor the quality and safety of the service provided to people living in the community.

The provider was conspicuously and legibly displaying their CQC rating at the premises and on their website.

Since our last inspection we had received a number of concerns that related to areas including sufficient staffing, staff turnover, activities and management of the home. We identified breaches of seven of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which were in relation to person centred care, dignity and respect, need for consent, safe care and treatment, meeting nutritional and hydration needs, good governance and staffing. We made one recommendation, which was in relation to how the provider handles informal complaints.

Due to the concerns we identified during our inspection, we wrote to the provider and requested they take a number of voluntary actions. This included ensuring all care plans and risk assessments be reviewed by the end of January 2017, reviewing staffing levels, assessing staff competence, keeping CQC informed about the recruitment of a suitable deputy and sending CQC an action plan. The provider agreed to take these actions. We requested the provider sends us evidence of these completed actions, and will review this to inform our decision making as to whether any formal enforcement action is required. We will update the section at the end of this report once any enforcement action has concluded.

Because of our concerns, we also raised a number of safeguarding alerts with the local authority. These were not progressed formally under safeguarding, but were passed to the local authority’s quality assurance department to follow-up.

Bowerfield House is a purpose built care home owned and operated by Maria Mallaband Group. The home provides nursing and personal care for up to 26 older people living with dementia. It is a two storey building situated adjacent to a larger sister building on the same site. All bedrooms are single occupancy and some have en-suite facilities. There is a passenger lift providing access to the first floor, an enclosed garden area to the rear of the building and car parking is available within the grounds. At the time of our inspection there were 23 people living at the home.

We found medicines were not being kept safely, which presented a risk to people living at the home. On our arrival at the home we found a large quantity of medicines received from the pharmacy had been kept in the conservatory area of the home, which was accessible to people living at the home. We also observed one occasion when the medicines trolley was left open and unsupervised in the clinic room. Entry to this room was restricted only by a door guard that some people living at the home may have been able to release. We also found thickening agent was kept in an unlocked cupboard in the ground floor lounge/dining area, which presented a risk of asphyxiation if people inadvertently consumed this.

Staff had not regularly reviewed risk assessments in relation to areas including malnutrition, falls, and pressure sores. This meant the provider could not be certain that appropriate measures were in place to reduce such risks. We also found staff were not following guidance in one person’s care plan in relation to reducing their potential risk of choking.

Numbers of staff providing direct care and support to people had not increased since our last inspection, despite the interim manager at that time recognising that staffing levels at particular times of the day required review. The provider had started using a dependency tool, which indicated there were sufficient numbers of staff. However, this tool did not consider factors such as the layout of the building, or the times of the day when additional staff support might be required. We observed that people did not always receive the support they needed in a timely manner, including support to get up in the morning, use the toilet, and to eat and drink. Staff and relatives expressed concerns that staffing levels did not always allow for sufficient supervision of people who may be at risk of falls.

We observed that people who required encouragement or prompting to eat and drink did not always receive the support they required as staff were engaged supporting people on a one to one basis or providing other care to people who required two staff to support them. On one occasion we observed two people had been sleeping with their meals in front of them uneaten, which were then removed by staff with no apparent encouragement or prompting provided for them to eat and drink. The provider changed the process for mid-day meals during the inspection to provide two sittings, which meant additional staff were available to provide support. However, we found there were on-going issues around the provision of support at breakfast and in the evening.

Care plans, including a care plan for a person receiving end of life care had not been regularly reviewed, and were not always reflective of peoples’ current support needs. The provider was in the process of carrying out comprehensive reviews of the care plans that had been completed for two people. However, this meant other care plans had not been regularly reviewed, which meant there was a risk care would not be planned to meet individuals’ needs and preferences.

We observed staff interactions with people living at the home were caring, patient, and empathetic. However, due to pressures on staff members’ time, interactions were often task based. Other than a pantomime on the first day of the inspection, we did not observe any attempts by staff to engage people in activities or other stimulation.

Systems and processes in the home were not always effective at ensuring people were treated with dignity and respect. We found one person was left for at least one hour without access to a call bell with their finished meal in front of them and wearing a clothing protector. We were informed by relatives that another person had been left without a duvet on their bed overnight as this had been taken to the laundry and not returned. Another relative told us that despite improvements in the laundry service, they would still find their family member wearing other peoples’ clothes.

Since our last inspection staff had started to receive regular supervision, and we saw training was carried out in a range of areas including safeguarding, moving and handling and infection control. The registered manager had identified areas where additional training was required, and had taken steps to ensure training that met specific learning needs was provided.

Relatives told us there had been a large turnover of staff, and this was also reflected in the information shared with us by the provider. Although relatives felt longer-term staff knew their family members well, it was felt that the regular use of agency staff and the turnover of staff had effected the consistency of care provided, as well as effective communication within the home.

Since our last inspection a registered manager had been appointed who was responsible for the management of Bowerfield House and the neighbouring care home, Bowerfield Court. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff and relatives were positive about the registered manager’s management of the home. They told us the registered manager appeared to be working very hard to try to improve the home. We received mixed reports about effective communication between relatives and staff at the home. Whilst some relatives were confident to approach staff or the registered manager, other relatives told us due to the registered manager managing two homes they felt they were not always accessible.

Record keeping at the home was poor. We found gaps in records of care provided and records, including records of food and fluid intake were not always updated in a timely manner. Record keeping in relation to wound care was poor, and although there was no evidence of actual harm as a result of this, we found staff were not clear about the care needs of one person with a wound.

There were systems and processes in place to help the registered manager and provider monitor and improve the quality and safety of the service, but these had not always been completed consistently and had not been effective at addressing identified concerns in a timely way. For example, we saw issues in relation to meal-time support had been identified in audits by both the registered manager and provider, and this issue had also been discussed at a relatives meeting. However, we found no effective actions had been taken to address this area of concern at the time of our inspection.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to be

We looked at three care records. We saw that assessments of health needs were carried out and that family members were involved as appropriate.

We saw that the home had systems and processes in place to ensure that the quality of the service was monitored.

People who lived at the home said they were happy with the care and support provided and that they were looked after. They told us that staff respected their rights, their privacy and their dignity. All three people we spoke with said they felt safe. One person said: "They treat me well and know me inside out.' People told us that they liked their rooms, that they enjoyed the food and that staff were polite. They said they had choice and staff consulted them about their care. The family members we spoke to were positive regarding the care people received at the home. Comments included: 'It's a lovely place' and 'Staff are so supportive.'

We found that people felt confident to express any concerns. Members of staff had a good understanding of safeguarding procedures and told us they would report any concerns immediately.

We noted that all staff members received the training and support they needed in order to provide safe and effective care for people using the service.

We found that systems were in place to monitor the quality of the service provided. We saw evidence to demonstrate that people were regularly consulted about all aspects of the care and facilities provided at the home