Bon Secours

Updated 25 June 2021

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 Care Act 2014.

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

The inspection was carried out by one inspector.

Service and service type

Bon Secours 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 had a manager registered with the Care Quality Commission. 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.

Notice of inspection

This inspection was announced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We sought and received some feedback from the local authority and professionals who work with the service. The provider was not asked to complete a provider information return prior to this inspection. This is information we require providers to send us to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made the judgements in this report. We used all of this information to plan our inspection.

During the inspection

We spoke with three members of staff including the registered and deputy manager. We spoke with two people living at the service. We reviewed a range of records. This included two people's care records and their medicine records. We looked at three staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

Updated 25 June 2021

About the service

Bon Secours is a residential care home providing care for up to three people. At the time of our inspection, the service supported three people who were living with a learning disability, two of whom are also supported with their mental health. Two people who used the service received support with personal care. This is help with tasks related to personal hygiene and eating. Where people received this support, we also considered any wider social care provided.

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

People told us they felt safe, they were happy living at Bon Secours and liked the staff who supported them.

The premises looked clean and tidy and had controls in place to minimise the risks posed by COVID-19. However, the provider was sharing some staff between two locations run by the same registered manager and operated by the same provider. This was contrary to current guidance and following the inspection the provider was told to stop this practice.

People received care and support personalised to their individual needs and suited to their communication preferences. Risks had been identified and care plans mostly provided guidance how to minimise risk. When pointed out to them, the registered manager gathered more information for people who may be at risk of epileptic episodes. Staff had received training about how to meet people’s needs and how to identify areas of concern.

The registered manager had identified outstanding notifications of events which should have been sent to CQC, when they had occurred. These were retrospectively submitted to us before this inspection. However, this had not permitted our oversight of events at the service as and when they occurred; without notification, CQC would not have known to take action if required. This demonstrated a lack of effective oversight and systems within the service.

Medicines were stored and managed safely; people received their medicines as prescribed. Guidance set out when ‘as and when needed’ (PRN) medicines should be given. However, administration of some PRN medicine was not always recorded in line with the protocol relating to it. The registered manager reviewed and revised this process immediately following the inspection.

Staff told us how they would recognise signs of abuse and the actions needed if abuse was suspected. There were enough staff to provide safe care. Safe recruitment checks were completed to ensure staff were suitable to work with people.

The registered manager had a clear vision for the service and had developed an action plan for ways to improve the service.

The service was able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture.

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's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

Right support:

• The model of care and setting maximised people's choice, control and Independence.

Right care:

• Care was person-centred and promoted people's dignity, privacy and human Rights.

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff ensured people using services could lead confident, inclusive and empowered lives.

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 1 March 2018).

Why we inspected

There have been significant concerns identified at other locations run by the same provider. 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. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the safe 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 Bon Secours on our website at www.cqc.org.uk.

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 coronavirus and other infection outbreaks effectively.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified three breaches at this inspection in relation to safe care and treatment, governance and notification of other incidents.

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 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.