Bowerfield House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found a breach of regulation relating to oversight of the safety of the home as processes were not always suitably robust and did not always lead to the required action being completed. For example, there were delays in how the service complied with requirements around lift safety and completed refurbishment of the premises. There were systems in place to ensure lessons were learnt and relevant action was taken when something had gone wrong, these needed to be further embedded and developed. Where additional potential risks were identified during the visit, such as appropriate use of secure storage for thickening agents and access to disposable gloves for people living with dementia, these were responded to and quickly addressed by the management team. Where people had areas of skin damage these appeared to be healing but it was not always evident that people were being repositioned as often as needed or that specialist equipment, such as mattresses were set to the person’s individual needs. Some improvements had been made to manage medicines; however, further work was needed. Staff knew people’s needs and risks, and the service was now meeting expectations in relation to cleanliness and the management of infection prevention and control.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People spoke positively about living at Bowerfield House. Most people and families felt able to raise concerns and were confident that the new manager would take action to ensure any changes were made. However, plans were not always robust to consider people’s individual needs and how to reduce risk. For example, one person had 5 unwitnessed falls in 2 months and whilst some action had been taken this had not included additional checks of their wellbeing.

Staff felt information was suitably shared and they told us they felt able to raise concerns. Staff told us about recent training around supporting people who were distressed which had been implemented in response to an incident.

The provider had processes in place to ensure lessons were learnt in response to incidents. This included reflective learning and root cause analysis. These were not personalised, did not capture triggers and did not support the development of a greater understanding of how any incidents may have occurred. Therefore, opportunities for learning from incident were limited. The provider was very responsive to feedback and took timely action to address any concerns raised during inspection. Resources and training had been implemented within the home in response to some of the learning from recent incidents.

People told us staff knew them well and would support them to access any other services they might need including medical support and reviews with doctors.

Staff felt they worked well as a team to ensure people’s needs were met and that they knew people well and were therefore able to identify any changes in need in a timely way. Staff spoke of positive relationships when working with other services and agencies.

Partner agencies had no concerns about the service. General feedback was that appropriate referrals for advice were made and action was taken in response to any advice given.

People had initial assessments of their needs in place and risks, needs and care plans were regularly reviewed and updated. We saw that external assessments and advice were sought where required and this advice was incorporated into the daily care given. The new manager and provider had oversight of people’s support needs through clinical risk meetings. Records were not always robustly completed to support the meetings and ensure the safe management and escalation of changing needs. For example, we found one person who’s care plan stated they were able to reposition themselves but we observed this not to be the case, staff did not support or encourage this person to reposition. Another person had been assessed to be moved using a standaid but we observed this person was not able to consistently weight bear and therefore using this equipment could not be done safely. This placed people at risk of harm and the records and processes in place did not demonstrate either of these issues had been identified by the service.

People felt safe and told us they were confident staff knew how to meet their needs. People and families spoke highly of staff and the care given. However, people were not always protected from risks associated with the people they lived with as staff did not always have enough oversight of where people were across the home. Relatives told us, and we observed, people would mobilise across the unit and go into other people’s bedrooms. Staff were not always available to support these people and ensure they did not distress others who we cared for in their room.

Staff told us they had completed training in their responsibilities to safeguard people. Staff confirmed they felt confident and able to raise any concerns they may have.

We observed some aspects of poor care. However, the provider was consistently responsive to address any areas of concern we identified. For example, immediate action was taken to ensure disposable gloves were not freely available to people living with dementia, that bed brakes were always applied to beds and thickening powders were suitably locked away. Staff were seen to support people kindly and with patience and provide reassurance where this was needed. Staff were generally consistently available within the kitchen and dining area of the home.

Processes had not always led to people being kept safe. For example, the provider had checks of mattress pressure settings in place which had been signed by staff. However, we found that some people had a setting which was set incorrectly to their weight. The provider had processes for learning lessons to keep people safe. We saw evidence that where there had been safeguarding concerns that action had been taken which had included training for staff.

It was not always clear how people had been involved in developing and managing care plans and risk. People risks were not always well-managed. For example, care records did not always clearly detail people’s needs and risk, with conflicting information around people’s diets for example. This meant people may be placed at risk of harm from being given a diet which was inappropriate to their needs. Records did not demonstrate that personalised care was being delivered in line with an individual’s assessed need. For example, where people needed frequent repositioning to protect their skin integrity or thickened fluids to reduce the risk of choking when drinking. However, people and families were generally happy with how they were supported. People were confident that staff would recognise and address any areas of concern. Some families told us they had been asked for feedback about the care their relative received.

Staff told us that communication worked well and people’s needs and risk were clearly identified within records. Staff confirmed any information about people’s changing needs was shared in a timely way and they felt action was taken when things had gone wrong.

Observations of staff practice were mixed and we saw occasions where people had not been repositioned as often as identified in their assessed needs. We also noted positive interactions where staff supported people, provided appropriate reassurance and encouraged independence.

Processes were not always robust in identifying all areas of potential risk. A variety of risk assessments and checks were in place to reduce risk but these did not cover all common aspects of risk and was not being used effectively to ensure all staff were clear on how risk should be mitigated. For example, there had not been a risk assessment for people using the garden area and new staff had not signed the record to demonstrate they had read these risk assessments. The provider was responsive and took action to address and risk assess any aspects of risk brought to their attention during the inspection. People’s needs and risks were fully assessed and care plans implemented, although these records did not always demonstrate how people and their families had been involved in developing these. Systems were in place for oversight of people’s individual risk. For example, those at risk of falls, skin integrity issues and those at risk of weight loss had action taken to mitigate the risk. This included requests for input from dietician services. However, this process was not being used effectively. For example, we found over half the air flow mattresses we checked were set incorrectly, placing people at risk of skin integrity issues despite checks of settings being recorded by staff and many checks.

People told us they felt some areas of the home needed updating and furnishings needed replacing. People had personalised their bedrooms and were happy to spend time where they chose. However, we found that people were not always kept safe through the safe use of equipment, and there were areas of the home which were damaged such as bathroom cabinets and wardrobes without cupboard doors damaged walls and flooring.

The manager had a number of plans for the environment and redecorating. Staff did comment that some aspects of the home were tired therefore making it difficult to keep clean and storage space was limited. The provider told us work with their estates team to improve the environment was ongoing.

We observed some areas of the home where furniture was damaged and redecorating was needed. There was a limited storage within the home meaning that people had various equipment and stocks of products such as continence aids stored in their bedroom. Some areas, such as the conservatory, were not being utilised by people living at the home. A Temporary maintenance person was present during our visit and working on a number of aspects of improvement for the home. Some dementia friendly adaptation had been made to the home including front door coverings for people’s bedrooms. Further work to ensure the home was as dementia friendly as possible should be considered as part of the ongoing programme for updating the environment.

At the time of our visit the home did not have a permanent maintenance person in post. Checks and maintenance were being completed by other members of the provider’s team. However, records were not always being accurately maintained in one place to allow for ease of oversight and some delays in accessing external services, such as the lift were noted. The provider was recruiting to the post of maintenance. Systems for daily walk round were in place but not being utilised as fully as possible to ensure good practice. For example, thickening agents were not always securely stored where they were not accessible to people. This was quickly addressed by the management team when raised with them.

People and families spoke highly of the staff and felt there were sufficient staff to meet their needs. People commented on the improvements that having a consistent staff team brought and told us agency staff were no longer used at the home. One family member told us how the service ensured their relative was supported with staff of their preferred gender when receiving personal care. However, it was not evident that people who chose to stay in their bedroom received the same levels of support. There was limited evidence of social activity for people who required support on an individual basis.

The management team told us about the work that had been completed to ensure a consistent staff team and reduce the need to use agency staff. Staff told us they felt positive about the staff team and they all worked well together. Staff felt they had all the training and support they needed.

Staff generally appeared to be available and people’s needs were responded to and reassurance provided to people when this was needed. However, it was not evident there was always good staff oversight for people cared for in their rooms who were not able to summon assistance if they needed, despite checks being completed.

Processes were in place to ensure sufficient staff levels were in place based on people’s dependency and needs. Additional staff were in place to bridge gaps in the delivery of activities whilst the service recruited to this and other roles across the home. Whilst staff felt well supported, it was not always evident that they were having consistent supervision. The provider told us work was ongoing to ensure oversight of training specifically tailored to the needs of the people living at the home was in place. For example, in relation to supporting people living with dementia and de-escalation techniques, and support for people who become distressed, to ensure all staff, including those recently employed, had the necessary knowledge and skills. Suitable recruitment processes were being followed.

People told us the home was clean and tidy. Records indicated that people were supported to have regular personal care and although we noted some areas for further development with regard to oral care, people look content and well kempt.

Staff demonstrated a good understanding of infection prevention and control processes and used and disposed of personal protective equipment (PPE) appropriately. Staff told us they had the resources they needed to promote good infection control and had done relevant training. We were told additional cleaning equipment was on order including a steam cleaner to help deep clean the home.

Domestic staff worked hard throughout the day to ensure the home was clean and tidy. PPE including disposable gloves and aprons, were readily available around the home. We discussed the potential risk these can pose to people living with dementia and the provider took immediate action to reduce this risk.

Improvements had been made in the recording and checks of the service regarding infection prevention and control. The service was in the process of recruiting additional domestic staff to fill any gaps in the rota in line with the needs of the home.

Improvements had been made in how people were supported to take their medicines. Medicines were administered safely and at the right times. All necessary records were in place before medicines were administered covertly. Medicines were disguised in an appropriate and safe way. However, guidance on administering some ‘when required’ medicines was insufficient to help staff decide when to give people these medicines, meaning that people may not receive the ‘when required’ medicines they need when they need them to promote their wellbeing and comfort.

All care staff received medicines awareness training and nurses completed medicines refresher training annually. The nurse on duty told us that nurses completed e-learning about medicines annually and had their competencies to safely manage medicines assessed.

Improvements had been made to how medicines were being safely administered and appropriately recorded. We found medicines were stored securely and medicines were kept at the right temperature; Controlled drugs were managed safely. Staff followed the company’s medicine policy when disposing of medicines. Daily and monthly medicine audits were conducted. No shortfalls were identified for the previous three months. However, non-medicated creams were left unlocked in people’s rooms and thickening powders had not always been appropriately stored in their lockable boxes.