Bishopsmead Lodge

Updated 18 August 2022

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 Health and Social Care Act 2008.

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

Bishopsmead Lodge is a nursing 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.

Registered manager

The home 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 unannounced.

What we did before inspection

Before the inspection we reviewed all of the information available to us, including any information of concern, notifications and the provider information return (PIR). This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make.

During the inspection

We spoke with the registered manager, regional manager, four staff, five people who lived at the home and one relative. We observed how staff interacted with people. We considered all this information to help us to make a judgement about the home. We looked at a range of records relating to the management of the home. This included recruitment records, risk assessments, medicines records, infection control practices and quality assurance records.

We continued to review the information we received from the inspection to help us make judgements about the home.

Updated 18 August 2022

Bishopsmead Lodge provides personal and nursing care for up to 51 people. At the time of the inspection, 40 people were living at the home.

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

There had been significant improvements following the inspection of 9 May 2019. Positive changes had been made to the management team. The registered manager had been in post for three years. A deputy manager worked alongside the registered manager. The regional manager visited the home regularly to provide good oversight. Governance audits had improved and had helped to address any shortfalls within the home.

Changes had been made in relation to the medicines system. The registered manager and deputy monitored the medicines systems and addressed any shortfalls. The home had a steadfast team of nurses and care staff employed. There was enough staff to safely provide care and support. We received good feedback about staffing levels at the home. All staff understood their responsibility to keep people safe from harm. Risks to people had been assessed with actions in place to help keep people safe. Checks were carried out on staff before they started work to assess their suitability.

Staff were enthusiastic and happy in their work. They felt supported within their roles. Staff described working together as a team, they provided person-centred care and helped people to achieve their potential.

Rating at last inspection

The last rating for this service was Requires Improvement (published 20 June 2019). At our last inspection we found further improvements were needed to the medicines system. We received mixed views about staffing levels at the home. Further improvements were needed to the quality monitoring audit process to help address shortfalls. The home needed to demonstrate that changes and improvements were consistent, embedded and sustained. We carried out an infection prevention and control inspection on 3 March 2022. We found that staff were not always wearing PPE such as surgical masks safely and gloves were not disposed of within clinical bins. At this inspection we found improvements had been made.

Why we inspected

We carried out an inspection of this service on 9 May 2019. We rated the service requires improvement in Safe and Well Led due to the shortfalls, which we identified. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led.

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 Requires Improvement to Good. This is based on the findings at this inspection.

Follow up

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

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