We carried out a review of the data available to us about Bishopsmead 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 Bishopsmead Lodge, you can give feedback on this service.
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.
People's experience of using this service and what we found
People told us they were supported by staff who wore personal protective equipment (PPE). They told us, “They do wear gloves and mask” and “Yes, they put their apron when giving me a wash”. We inspected the service and were not assured the service was managing infection control procedures relating to the risks of coronavirus and other infection outbreaks effectively. Staff were not always wearing PPE such as surgical masks safely and gloves were not disposed of within clinical bins. The cleaning of keypads required improving and where staff were working across different floors there was a risk of cross contamination due to poor PPE practices.
We found the following examples of good practice.
People had been supported to keep in touch with families. This had included outside visits and inside visits for those who were receiving end of life care.
Risk assessments were completed, and there was signage and guidance for visitors to follow. There was a system in place to take visitors temperature on arrival and record contact details for test and tracing purposes. When people were admitted to the home, risk assessments were completed, and people were isolated in line with current guidance. Social distancing was encouraged throughout the home.
There were donning and doffing stations located outside people’s rooms. Staff had access to plenty of PPE and staff had received training in infection prevention control.
The provider was testing staff every week. This included testing agency staff.
People’s experience of using this service and what we found
We inspected the service and were assured the service was managing infection control procedures relating to the risks of coronavirus and other infection outbreaks effectively. For example, we found staff had access to plenty of personal protective equipment (PPE) however, we observed some staff had twisted their masks which could cause the mask to be ill fitted. Staff confirmed they changed their face mask in between supporting people with personal care. Although we did not observe this practice this is not in line with current guidance that confirms face masks can be used while caring for a number of different residents regardless of their symptoms. We highlighted this to the management team who planned to discuss these issues with staff.
There were designated areas where staff could access PPE throughout the service, however additional pedal bins were required in some people’s bedrooms as at the time of the inspection as there were red disposable bags with used PPE hanging from door handles. This could increase the risk of cross infection due to people and staff being exposed to PPE that was dirty and contaminated.
We found the following examples of good practice.
People were supported to keep in touch with families. This included visits within the service in the entrance lobby and visits for those who were receiving end of life care. Risk assessments were completed and there was signage and guidance for visitors to follow.
The service had good relationships with the local community, and a number of events and initiatives had taken place during the pandemic.
There was a system in place to take visitors temperature on arrival and record contact details for test and tracing purposes. People had their temperatures checked daily and staff were aware of the different symptoms people could have if they had contracted coronavirus. Additional cleaning regimes were in place to ensure high standards of cleaning. This included paying attention to high touch areas such as door handles, light switches and bannisters. The service was clean and odour free.
The movement of staff between different areas of the home was minimised. The provider was testing staff every week and people monthly. The service was not using agency staff currently.
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
Bishopsmead Lodge is a care home that provides personal and nursing care for up to 51 older people. The service is provided in purpose built accommodation over two floors. At the time of the inspection, 36 people were living at the home.
What life is like for people using this service:
People who used the service and relatives spoke positively and told us they felt safe in the home.
Improvements had been made to the management of medicines. Further improvements were needed to make sure actions were promptly taken when shortfalls were identified.
Staff had received sufficient training to carry out their roles. Staff demonstrated a good understanding of safeguarding and whistle-blowing and knew how to report concerns.
People were supported to access health care services and regular visits were undertaken by the GP. Healthcare professionals recognised that improvements had been made and the quality of care people received had improved. Their feedback also confirmed that further improvements were needed.
People’s dietary needs were assessed, and people were offered choices at mealtimes. Improvements were needed to make dining in communal areas a consistently positive experience.
Where people’s foods, fluids and change of position needed monitoring, records had improved and those we saw were complete and up to date.
People and relatives were asked for feedback and knew how to complain. No-one was receiving end of life care at the time of our inspection visit.
People received care that was kind and respectful. Care plans were detailed and reviewed each month. Further improvements were needed to make sure changes were fully incorporated and clearly recorded.
The service worked in partnership with other organisations to make continuous improvements to the provision of activities.
The service met the characteristics of Requires Improvement in the key questions Safe and Well-led, and Good in the key questions Effective, Caring and Responsive. Therefore, our overall rating for the service after this inspection remains Requires Improvement.
More information is in detailed findings below.
Rating at last inspection:
Requires Improvement (report published in May 2018).
Why we inspected:
Services rated “requires improvement” are re-inspected within one year of our prior inspection. This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people receive.
Follow up:
We will monitor information received about the service to inform the assessment of the risk profile of the service and to ensure the next planned inspection is scheduled accordingly.
At the last inspection on 15 March 2017 the service was rated Requires Improvement. We found a breach in the regulation relating to personalised care. Following this inspection, the provider sent us an action plan telling us how they would make the required improvements.
We carried out a comprehensive inspection on 17 and 18 April 2018. At this inspection, we found improvements had been made in the recording of personalised care and the legal requirement was met. However we found three breaches in the regulations relating to the management of medicines, meeting nutritional and hydration needs and quality assurance systems.
The service remains Requires Improvement.
There was a registered manager in post. 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.
Medicines were not always safely managed. The provider’s monitoring and checking systems had not picked up when medicines had not been given as prescribed. This meant people were at risk of not receiving the care and treatment they needed.
There were on-going organisational safeguarding investigations at the time of our inspection, due to a number of care concerns raised. The provider had been required by the local authority safeguarding team to complete a protection plan to demonstrate that people were safe in the home.
Risk assessments and risk management plans were completed. Incidents and accidents were recorded and the records showed that required actions were taken to minimise future occurrences.
Sufficient numbers of staff were deployed at the time of our visit. There were significant registered nurse vacancies and the home was reliant on agency registered nurses on a regular basis each week to provide clinical expertise and leadership. Staff performance was not effectively monitored. Improvements were needed to make sure staff received supervision in line with the provider’s policy, and to make sure they could meet people’s needs.
Appropriate health and safety checks were undertaken to reduce risks to people. The home was clean and on most occasions staff followed the homes infection control policy and procedures.
People were not always provided with the support they needed with food and fluids and records were not accurately maintained. People’s dietary requirements and preferences were recorded and people were provided with choices at mealtimes.
People’s legal rights were respected. People were supported to exercise control, consent to care and make decisions. The principles of the Mental Capacity Act (MCA) 2005 had been followed.
Staff were kind and caring. We found people were being treated with dignity and respect and people’s privacy was maintained.
People who used the service felt able to make requests and express their opinions and views. People were helped to exercise choice and control.
The service that was not consistently well-led. Systems were in place for monitoring quality and safety. However, shortfalls in care were not always identified.
Bishopsmead Lodge is registered to provide accommodation for persons who require personal or nursing care for up to 51 people. The service cares for older people, some of whom are living with dementia. At the time of our inspection there were 42 people living in the service.
There was a registered manager in place on the day of our inspection. 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.
In the main care plans contained risk assessments for areas such as falls, moving and handling and skin integrity and where risks had been identified the plans guided staff on how to reduce the risks. For example, plans contained hoist and sling details when required. Care plans did not reflect people’s individualised needs. The quality and content of care plans were variable.
We found that arrangements in place for managing medicines were in the main managed safely. Some medicines were not stored correctly, in line with legal requirements. This was identified in a previous pharmacy check. Staff told us they were in the process of obtaining a new store cupboard for these medicines.
People's rights were in the main being upheld in line with the Mental Capacity Act (MCA) 2005. This is a legal framework to protect people who are unable to make certain decisions themselves. In people's support plans we saw information about their mental capacity and Deprivation of Liberty Safeguards (DoLS) being applied for. These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely.
Records showed that a range of checks had been carried out on staff to determine their suitability for work. Staff were supported through an adequate training programme but further work was required regarding holding regular supervision. Supervision is where staff meet one to one with their line manager.
The staff we spoke with had a good awareness and understood their responsibilities with regard to safeguarding people from abuse. Staffing rotas viewed demonstrated that staffing levels were maintained in accordance with the assessed dependency needs of the people who used the service.
We observed some positive interactions between people and staff throughout the inspection. There was plenty of laughter and the atmosphere was calm and friendly. Staff were knowledgeable about people's needs and were aware of their life histories and background. Staff told us how people preferred to be cared for and demonstrated they understood the people they cared for.
People spoke positively about the activities offered and told us the programme was varied and enjoyable. Relatives were welcomed to the service and could visit people at times that were convenient to them. People maintained contact with their family and were therefore not isolated from those people closest to them.
People had access to on-going healthcare services. Records showed that people were reviewed by their GP, the physiotherapist, the tissue viability nurse, the chiropodist and the dementia well-being team.
Although regular staff meetings were not held staff felt well supported by the registered manager.
People advised that they would be either extremely likely or likely to recommend the service to friends and family if they needed similar care or treatment. They felt listened to and staff treated them with respect.
We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.