Background to this inspection
Updated
8 March 2023
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 team was made up of two inspectors and one Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.
Service and service type
Bedborough House is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Bedborough House is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.
Registered Manager
This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.
At the time of our inspection there was a registered manager in post.
Notice of inspection
This inspection was unannounced.
What we did before inspection
We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.
During the inspection
We communicated with 5 people, 7 staff and 5 relatives. We looked at various records in relation to the running of the service including recruitment files, activities records and checks and audits of quality and safety. We toured the premises and made observations of interactions in communal areas.
Updated
8 March 2023
About the service
Bedborough House is a residential care home providing the regulated activity accommodation for persons who require nursing or personal care to up to 8 people. The service provides support to autistic people, younger adults and people with learning disabilities. At the time of our inspection there were 6 people using the service.
Accommodation is laid out over 3 floors. Communal lounge and dining rooms are located on the ground-floor and bedrooms are located on the 1st and 2nd floors. All bedrooms have en-suite facilities and 4 have lockable kitchenettes. People have access to a communal kitchen and a large garden. The registered manager’s office is located on the 3rd floor.
People’s experience of using this service and what we found
Right Support: Areas of the service were visibly unclean and had not been adequately maintained. We observed staff smoking in close proximity to people’s accommodation. There were sufficient numbers of staff to keep people safe. A positive behaviour support coordinator analysed potential triggers of behaviours that may challenge others to help prevent a recurrence.
People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.
Right Care: Staff spoke about and treated people in a person-centred way. The provider had introduced equality and human rights care plans to support staff to identify and promote these needs. People were supported to maintain relationships with relatives and friends important to them.
Right Culture: Audits and checks were not always used effectively and consistently to identify shortfalls and drive improvement in the service. Staff spoke positively about the registered manager. The registered manager said activities provision was an area for development and records did not always reflect what activities people were involved with.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update: The last rating for this service was good (published 19 January 2021).
Why we inspected
We received concerns in relation to the management of medicines and staffing. As a result, we undertook a focused inspection to review the key questions of safe 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 and well-led sections of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bedborough House on our website at www.cqc.org.uk.
Enforcement
We have identified breaches in relation to the application of the Mental Capacity Act (MCA), the safety of the premises and the efficacy of checks and audits.
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.