We carried out a review of the data available to us about Bullsmoor Lodge on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Bullsmoor Lodge, you can give feedback on this service.
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.
We found the following examples of good practice.
The service had effective infection, prevention and control measures in place to ensure people, their relatives and staff were protected from risk of infection.
Systems were in place to facilitate safe visits to the service. Relatives who visited were able to use a dedicated entrance and meeting spaces and had access to appropriate Personal Protective Equipment (PPE) and COVID-19 testing.
Premises were regularly cleaned, and high touch areas were disinfected regularly. People were socially distanced where possible and had their health routinely monitored by staff.
Staff were provided with appropriate training, PPE and access to COVID-19 testing. Infection prevention and control policies were reviewed regularly and made accessible to all staff. The registered manager sought advice from relevant authorities when needed.
At our last inspection on 2 April 2016 we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.
People told us they felt safe. Sufficient staff were employed. Staff were safely recruited. Risks to people's health were assessed and understood.
The home sought treatment and advice from specialist health and social care professionals, where needed, to ensure people received safe care that met their needs. Medicines were stored and administered safely.
Staff had received regular training, supervision and an annual appraisal to support them to provide effective care. People had choice around what they ate and were supported to maintain good health. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.
We observed kind and caring interactions between people and staff. People living in the home and their relatives praised the caring nature of the care staff and registered manager. People were supported to increase their independence. People were involved in planning their care.
Care plans were person centred, detailed and updated as and when people's care needs changed. People were supported to lead active and fulfilling lives. Systems were in place to manage complaints.
People and relatives told us they were happy with the overall service at Bullsmoor Lodge. Quality assurance processes were in place to monitor the quality of care delivered. The registered manager worked in partnership with external health and social care professionals to ensure people's health and social care needs were met.
Further information is in the detailed findings below.
Bullsmore Lodge cares for 48 older people providing accommodation and personal care. The service mainly focused on meeting the needs of people with dementia. There were 46 people using the service on the day of our inspection.
The home had a registered manager. 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.
People were provided with a choice of food, and were supported to eat when required. People were supported effectively with their health needs.
People were involved in decisions about their care and how their needs would be met. Staff knew what to do if people could not make decisions about their care needs in line with the Mental Capacity Act 2005.
People were kept safe from the risk of abuse. Risks to people were identified and staff took action to reduce those risks.
There were systems in place to ensure that people consistently received their medicines safely and as prescribed.
Sufficient staff were available and they had the necessary training to meet people's needs. Staff responded to people’s needs promptly.
Care was planned and delivered in ways that enhanced people’s safety and welfare according to their needs and preferences. Staff understood people’s preferences, likes and dislikes regarding their care and support needs.
People were treated with dignity and respect. There was an accessible complaints policy which the registered manager followed when complaints were made to ensure they were investigated and responded to appropriately. People and their relatives felt confident to express any concerns.
People using the service, relatives and staff said the registered manager was approachable and supportive. Systems were in place to monitor the quality of the service.
We spoke with people who used the service and relatives of people who used the service. Additionally we spoke with staff at varying levels within the home.
We viewed records including care records of six people, staff files of six people, medication records and policies and procedures.
Below is a summary of what we found. The summary describes what people using the service, those acting on their behalf and staff told us and what we observed.
If you want to see the evidence that supports our summary please read the full report.
Is the service safe?
Records showed people experienced safe care. Their needs had been assessed and their care and treatment planned and delivered in accordance with individualised care plans. We found staff recruitment procedures to be effective and safe and people were being cared for by suitably skilled and competent staff. Procedures were in place for dealing with emergencies and staff were suitably trained to ensure people's safety and welfare.
Is the service effective?
A person living at the home told us, "I think the care here is good," another told us "I like the way they look after you here." Feedback from those acting on behalf of people was very positive on the whole about the home and standards of care. Our findings evidenced people experienced effective care. People's needs had been assessed and individualised care plans were produced which reflected their needs and wishes. The assessments and care plans addressed people's physical, communication, emotional and social needs. They showed staff promoted and respected people's diversity, privacy and spiritual beliefs. The care plans included information about how people wished to receive their personal care, highlighted personal food preferences and a relative we spoke to told us how staff supported her father to attend church.
Is the service caring?
Relatives of people gave positive feedback about staff and said they were caring. One person told us "They couldn't have been more helpful than she was." We found staff to be knowledgeable about people's preferences, for example, their choice of food and beverages and these were accommodated. We saw high levels of engagement between staff and people who used the service and visitors. Generally activities both in the home and community had been organised to accommodate people's interests and with their involvement. This demonstrated staff understood and respected people's lifetime experiences and interests.
Is the service responsive?
We found staff were attentive to people, engaged them in social interactions and stimulating activities. We also saw staff respected the wishes of people not to participate in organised group activities and provided opportunities for individual support. A relative told us the provider was approachable and accessible to them when they visited and were responsive to their relative's needs.
Is the service well-led?
Discussions with the provider and care staff confirmed they understood their roles and responsibilities. The provider gave staff clear direction and guidance, providing opportunities for both formal and informal supervision and support for staff. Staff told us they felt supported and had opportunities to develop their skills through further training.
Staff said that they had been supervised and supported in their work. There were records of supervision available and these showed that staff had been able to discuss their training and development needs. The manager explained that supervision would be linked to ongoing appraisal of staff. There were plans to have quarterly meetings at which staff would be able to discuss their development needs and receive feedback on how well they were performing.
Our inspection of 16 September 2013 found that information about the complaints system was not brought to the attention of people who use the service and their relatives. The provider wrote to us and told us that they would make sure that people and their relatives were aware of the complaints procedure, and that any complaints were addressed. At this inspection we saw that copies of the complaint policy were available for people and their relatives so that they would know how to make a complaint. One person said, 'I know I can tell them if something is not right and they would do their best to sort it out.'
People's complaints were fully investigated and resolved, where possible, to their satisfaction. The manager told us that they had been one formal complaint since the last inspection. There was a record to show how this complaint had been investigated. This clearly outlined the findings of the complaints investigation. As a result of this complaint changes had been made to how the service communicated with people and their relatives.
People were protected against the risks of receiving care that was inappropriate or unsafe. All people had an individual care plan that was reviewed on at least a monthly basis.
There were enough qualified, skilled and experienced staff to meet people's needs. Recruitment processes were in place and had been followed. Staff response to call bells and requests for assistance was prompt.
People were not always cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Not all staff received appropriate training, professional development, supervision and appraisal.
There had been no complaints recorded by the home since our last inspection. However, the complaints procedure had not been brought to the attention of staff, service users and those acting on their behalf, and they were unclear of the process.
They confirmed that staff assisted them when they needed support with their care and that staff were very helpful. One person commented, 'I get on with all of them.' People told us the staff were 'polite' and supported them with, 'warmth and humanity.'
People were able to express their views and were involved in making decisions about their care and treatment. People told us that they were offered choices in relation to how they wanted to be supported. They told us that they had regular meetings to talk about their care and could comment on how the service was run as well as make suggestions for improvements.
People told us that they felt safe with the staff who supported them. They said they had no concerns or complaints about their care but would speak with their relatives, the manager or the care worker if they needed to. One person told us, 'I've got nothing to worry about at all.'
Staff told us they felt supported by the management and that there were good training opportunities available within the organisation. Staff were able to tell us how the training they had undertaken informed their working practices.
We observed staff supporting people in a friendly and professional way and saw that people were being offered choice with regard to menus and activities.
People told us that staff listen to them and involve them in aspects of their care and the general activities in the home.
One person told us, 'They all seem to be out to help you'.
People gave us examples of how they are given choices about their care and what they like to do. They confirmed that the management and staff included them in some decisions about the running of the home. People told us that they had good contact with the local community.
Staff we interviewed were able to give us examples of how they maintain peoples' dignity, privacy, independence and how they offer choices to people on a daily basis.
We asked people who use the service what they thought about the care and treatment they received at the home.
They responded positively and comments included, 'I can honestly say I've no complaints about this home' and 'They do very well.'
People said they felt supported by the staff team and they were included in decisions about their care as far as possible.
One person commented, 'They have talked about my needs and my likes and dislikes'.
People told us they were satisfied with the activities available at the home and that they could go out if they wished to.
Comments included 'There are a lot of things you can do' and 'There are lots of activities in the lounge; I particularly enjoy the quiz and armchair aerobics'.
We saw activities taking place during our visit and the atmosphere was lively and inclusive.
People told us they were happy with the way the home organised outside health care visits such as doctors, chiropodists and district nurses. One person commented, 'They all come in regularly'.
Staff we spoke to confirmed that they asked people how they wanted to be supported at the home. Staff also demonstrated a good understanding of the care needs of people they supported.
People who use the service told us they felt safe at the home and that they would talk to the manager or staff if they were concerned about anything. One person commented, 'And I'd feel comfortable doing so'.
Staff we interviewed were aware of the different types of abuse that can happen to people in a care setting. Staff were also able to give us examples of signs they would look out for that may indicate a person may be being abused.
Staff told us that if they ever suspected abuse was taking place they would inform the manager immediately.
We asked people who use the service about how the home deals with their medication. One person commented, 'I take lots and the staff explain to me what it's for if I ask'.
We had a moderate concern about the management of medicines at the home and have issued a compliance action to ensure improvement in this outcome area.
People told us that they had confidence in the staff team and that staff responded to their needs appropriately. Comments included, 'They do very well', 'I think they do a very good job' and 'I've never had to wait for more than a few minutes'.
Some people felt that there could be more staff at the home and that they could spend more time with them. One person told us, 'When they have finished their duties they go to the staff room. I miss the conversation'. Another person told us, 'They have problems when people are on holiday or off sick, they are understaffed then as they have nothing to fall back on.'
We observed staff being appropriately supported by the management so that they could provide for the care needs of the people who use the service.
We found that some staff needed to undertake some essential training and have issued a compliance action in relation to this.
We asked people who use the service what they thought about the quality of care they receive at the home.
People were positive about this and told us they were asked for their view about the quality of service provision at meetings and in one to one sessions.
One person commented, 'They want to know if you're comfortable'.
People told us they felt the service listened to their views and opinions.
Although health and safety checks were being carried out intermittently, we have issued an improvement action that these systems are more regular and formalised so that the provider can regularly identify, assess and manage any potential risks to peoples' health, welfare and safety.