Bishop's Cleeve Care Home

Bishop’s Cleeve Care Home is a purpose built residential care home providing personal care to up to 64 people. The service provides support to older people. The home has 4 separate units, one of which specialises in supporting people who live with dementia. At the time of the inspection there were 33 people using the service living across 3 of the units.

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

People and relatives told us they felt safe and were positive about the care received, however we found robust risk mitigation plans were not always in place for all people and staff were not given clear guidance or information on how to protect people from associated risks. Not all staff knew how to support people to manage their risks. People were not always robustly protected from the risks of their environment.

Medicines are not always managed safely for people living at the service.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests.

People’s care and support was not always delivered in a person-centred way.

Systems to monitor and improve the quality and safety of the service were not always effective. Records to support the management of the service had not always been maintained.

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 15 August 2022).

Why we inspected

We received concerns in relation to the management of the service, the quality of people's care and support and the management of risks to people. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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 that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bishop’s Cleeve Care Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, safeguarding, person centered care and good governance.

Please see the action we have told the provider to take at the end of this report.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Bishops Cleeve Care Home is a residential care home providing personal care to up to 64 people. The service provides support to older people. At the time of our inspection there were 29 people using the service.

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

The home was well led by a management team who were passionate about providing high quality and individualised care to people. The registered manager and deputy manager led by example and without exception staff told us that they were well supported.

Robust quality assurance systems and a strong learning culture across the organisation contributed to continual development and improvement of the home. The registered manager told us, “The provider has allowed me to find my feet as a registered manager and grow in the role. We have so many mechanisms in place to ensure we continually develop the home.”

There was a culture of listening to people and positively learning from events so similar incidents were not repeated. As a result, the quality of the service had continued to grow and develop.

People received their medicines in a safe and timely way. Staff had received training in recognising safeguarding and knew the actions to take to protect people from harm. There were safe recruitment processes in place and checks were carried out before staff were appointed.

The provider had infection control procedures in place to protect people and prevent the spread of infection. Staff accessed personal protective equipment (PPE) and acted in accordance with government guidance.

People received person-centred care based on their individual needs, choices and preferences. Staff who supported them were aware of their individual preferences and were knowledgeable about people's needs and how these should be met. Staff treated people with kindness, dignity and respect and spent time getting to know them. Care plans reflected people's likes, dislikes and preferences. There were a variety of activities available for people to engage with.

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.

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

Rating at last inspection

This service was first registered with us on 22 March 2021. There was a change of provider entity on 1 February 2022 and this is the first inspection.

Why we inspected

This service had not been inspected since their registration in March 2021. This inspection was carried out to gain assurances about the quality of care and systems used to monitor and manage the service.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.