Bowbridge Court

Bowbridge Court is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Bowbridge Court does not provide nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Bowbridge Court accommodates up to 54 people in one purpose-built building, which is split across three floors. One of the floor specialises in providing care to people living with dementia. On the day of our inspection 45 people were living at the service.

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

Staff were not consistently using personal protective equipment (PPE) effectively. The registered manager took action to address this. The service was kept clean, which minimised the risk of people acquiring an infection. We were assured that the provider was preventing visitors from catching and spreading infections and were assured that people were admitted safely to the service. Staff were not always deployed effectively to meet people’s needs.

People and relatives said they felt the service was safe. The registered manager and provider took appropriate action to ensure people were protected from the risk of abuse. People’s needs were assessed, and risks associated with their health conditions documented. Staff knew about risks associated with people’s health conditions and understood how to provide care which kept people safe. Risks associated with the service environment were assessed and mitigated.

People received their prescribed medicines safely. The system for managing medicines ensured people were given the right dose at the right time. Accidents and incidents were reviewed and monitored to identify trends and to prevent reoccurrences. The provider had improved their processes for analysing incidents to determine how to improve the quality of care.

The service was well-led. People and their relatives spoke positively about the way the service was run. The provider and management team undertook audits of all aspects of the service to review the quality of care, and identify areas where improvements were needed. This included a range of regular checks on all aspects of people’s care, and the building environment. Staff we spoke with clearly understood their roles and responsibilities in providing people with safe and good quality care.

People, relatives and staff were encouraged to give regular feedback on the quality of the service. Staff worked with other health and social care professionals to ensure people received the care and support they needed.

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 Requires Improvement (published 2 May 2019) and there were breaches of regulations 12, 13 and 17 of the Health and Social Care Act Regulations 2014. Following the last inspection, we retained conditions already imposed on the provider’s registration. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about medicines management, infection prevention and control, staffing levels and how risk is managed for people’s behaviours. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the Safe and Well-led sections of this full report.

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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. 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 Requires Improvement to Good. This is based on the findings at this inspection.

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

Follow up

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

Bowbridge Court was rated as requires improvement at our last inspection in April 2018. During this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to safe care and treatment, safeguarding and governance. You can see what action we told the provider to take at the back of the full version of the report. 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.

There was a registered manager in post at the time 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.

During this inspection we found ongoing concerns about the safety of people living at the home. Sufficient action had not been taken to protect people from the behaviour of others living at the home, this placed people at risk of harm. Systems to review and learn from accidents and incidents were not fully effective. Action was not always taken to protect people from improper treatment or abuse, and referrals were not consistently made to the local authority safeguarding adults team. People were not always protected from risks associated with their care and support, such as falls.

Medicines were stored and managed safely and people received their medicines as required. Improvements were underway to ensure the home was clean and hygienic and effective infection control procedures were in place.

Improvements had been made to ensure 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. People were supported by staff who had training and supervision. Overall, staff were skilled and knowledgeable. People had enough to eat and drink, mealtimes were positive sociable experiences and people were offered choices. Where people had risks associated with eating and drinking these were managed safely. People had access to healthcare and their health needs were monitored and responded to. Improvements were underway to ensure people’s health needs were fully reflected in their care plans. There were systems to share information between services to ensure care was person centred. The environment was adapted to meet people’s needs and people had been involved in the decoration of the home.

Staff were kind and caring in their approach and treated people with dignity and respect. Support was person centred and based upon those things that mattered most to people. People were involved in day to day decisions about their care and support. There were links with local advocacy services to enable people to express their views if needed. People’s right to privacy was respected and independence was promoted and encouraged.

People received the support they required from staff who had a good knowledge of their needs, wishes and preferences. Overall, care plans were detailed and reflected people’s needs. People were given the opportunity to discuss their end of life wishes and were given compassionate support at the end of their lives. People were very positive about the range of social and recreational opportunities available to them. People were supported to raise issues and concerns and there were systems in place to respond to complaints.

The home was not consistently well led. Systems to monitor and improve the quality and safety of the service did not consistently ensure risks were identified and addressed. People and their relatives were involved in giving their views on how the service was run and this was used to inform improvement. Staff felt supported, had confidence in the registered manager and were given opportunities to make suggestions to improve the quality of care. The management team were committed to making improvements and responded swiftly to concerns found at this inspection.

Bowbridge Court was rated as inadequate at our last two inspections which were in April and December 2017. During this inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to safe care and treatment, staffing, consent and governance. You can see what action we told the provider to take at the back of the full version of the report. 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.

There was a registered manager in post at the time 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.

During this inspection we found people were not always protected from risks associated with their care and support. Risks were not always identified, assessed or managed and this placed people at risk of harm. There were not always enough staff to ensure people’s safety and meet their needs. Adequate steps had not always been taken to ensure people were protected from staff that may not be fit and safe to support them.

People told us they felt safe and improvements had been made to protect people from abuse and improper treatment. Medicines were stored and managed safely and this meant people received their medicines as required. The home was clean and hygienic and effective infection control procedures were in place.

People’s rights under the Mental Capacity Act (2005) were not respected. People were subject to restrictions upon their freedom but their capacity to consent had not been assessed.

People could not be assured they would receive effective support in relation to their health. Health professionals were not always contacted quickly when people required specialist support and the advice of health professionals was not always followed. People had enough to eat and drink. However, improvements were required to ensure people’s needs and preferences were met.

The physical environment had been adapted to meet people’s needs and people had been involved in the decoration of the home. Improvements were planned to ensure the design and decoration of the home met the needs of people living with dementia. People were supported by staff who had training and supervision.

Staff were kind and caring in their approach and treated people with dignity and respect. People were involved in and consulted on day to day decisions about their care and support. There were links with local advocacy services to enable people to express their views if needed. People told us most staff understood what was important to them. This was not always reflected in care plans, but work was underway to make improvements. People’s right to privacy was respected and they were encouraged to maintain their independence.

Care plans did not always reflect people’s needs and preferences, improvements were underway to address this. People were given opportunities to get involved in meaningful activity and further improvements were planned to ensure people’s individual interests were taken into account. People were supported to raise issues and concerns and there were systems in place to respond to complaints.

Improvements to management and governance systems were underway but further work was required to ensure this was effective and sustainable. Systems to monitor and improve the quality and safety of the service did not consistently ensure risks were identified and addressed in a timely manner. People and staff were involved in giving their views on how the service was run. The management team were passionate about making improvements and had a positive impact on the quality of the service. They were open to feedback and took swift action to respond areas of concern raised during our inspection.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

At the last inspection in April 2017, we asked the provider to take action to make improvements to the safety of the service, consent, staffing, leadership and quality assurance. During this inspection we found the required improvements had not been made.

There was no registered manager in place at the time of our inspection. The previous registered manager had left Bowbridge Court at the start of December 2017. 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. There was a new manager in post at the time of our inspection who had been in post for a period of approximately two weeks at the time of our inspection visit. They informed us they would be submitting an application to register with CQC. We will monitor this.

During this inspection we found ongoing concerns about the safety of people living at the home. Action had not been taken to protect people from the behaviour of others living at the home, this placed people at risk of serious harm. Systems to review and learn from accidents and incidents were not consistently effective. Action was not always taken to protect people from improper treatment or abuse, and referrals were not consistently made to the local authority safeguarding adults team. People were not always protected from risks associated with their care and support, such as pressure ulcers. Medicines were not always managed safely. Equipment was not clean and hygienic.

There were not enough, adequately trained staff available to provide care and support to people at all times. Staff did not always have the necessary training to enable them to provide safe and effective support. Staff were not provided with regular supervision, this meant opportunities to monitor and improve staff practice may have been missed. Safe recruitment practices were followed.

Where people lacked capacity to make choices and decisions their rights under the Mental Capacity Act (2005) were not always respected. Some people had restrictions imposed upon their rights but we could not be assured this was in their best interests. People who had the capacity to make decisions were supported to have choice and control of their lives.

Systems to ensure people had enough to eat and drink were not consistently effective and this placed people at risk of insufficient food and fluid intake. People’s day to day health needs were met and they were supported to access healthcare as required. The physical environment had been adapted to meet people’s needs, further work was required to ensure people’s cognitive needs were met by the design and decoration of the home.

People’s right to privacy was not always respected. People told us the quality of care varied between staff members, this meant they could not be assured they would be provided with consistently kind and caring support. People felt involved in day to day decisions about their care and support and families were offered opportunities to be involved in developing their loved one’s care plans. People told us most staff understood what was important to them. However, this was not always reflected in care plans. People were encouraged to maintain their independence.

People were at risk of receiving inconsistent support as care plans did not provide an accurate or up to date description of their needs. People knew how to raise issues and concerns, however some did not feel comfortable doing so and the provider’s procedure for managing complaints was not followed in all cases. People were given opportunities to get involved in meaningful social activity within the home and the local community.

The service was not well led. There had been a failure to make and sustain improvements identified at our last inspection. Systems to monitor and improve the quality and safety of the service were not effective and this placed people at risk of serious harm. Swift action was not always taken in response to known issues. Staff did not always have a good understanding of their role and were not effectively managed or supervised.

You can see what action we told the provider to take at the back of the full version of the report. 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.

The overall rating for this service remains ‘Inadequate’ and the service therefore remains in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe, so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We inspected this service on 30 August 2016 and the service was rated as requires improvement with multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we found that the required improvements had not been made and found ongoing concerns in relation to the quality and safety of the service. This resulted in us finding new and ongoing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to safeguarding service users from abuse and improper treatment, consent, safe care and treatment, staffing and good governance. We also found an ongoing breach of regulation 18 of the Care Quality Commission (Registration) Regulations) 2009. You can see what action we told the provider to take at the back of the full version of the report.

There was no registered manager in post at the time of our inspection, our records showed that the previous registered manager had left the service in October 2016. 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. There was a service manager in place during our inspection who had taken over responsibility for the day to day running of the service in November 2016. They informed us that they would be submitting an application to register as manager for the service. We will monitor this.

During this inspection we found that the systems in place to reduce risks associated with people’s care and support were not always effective and this exposed people to the risk of harm. Risks in relation to people's care were still not planned for appropriately to ensure people received safe care and people's care records did not contain sufficient guidance for staff to minimise risks to people.

Although people felt safe in the service, they were still not always protected from the risk of abuse and information of concern was not always acted upon or shared with the local authority. People did not always receive their medicines as prescribed and medicines were not always managed safely. Equipment used to support people was not always clean.

There were enough staff to provide care and support to people. However safe recruitment practices were not always followed. Staff did not always receive suitable training or support to enable them carry out their duties effectively and meet people’s individual needs and were not provided with regular supervision and support.

People’s rights under the Mental Capacity Act (2005) were not respected. People could not be assured that restrictions imposed upon their freedom were appropriate or in their best interests. However, people told us they felt involved in day to day decisions about their care and support.

People’s day to day health needs were met, however, there was a risk that people may not receive appropriate support with specific health conditions due to a lack of information in care plans. Most people were supported to have enough to eat and drink. However a small number of people were placed at risk of malnutrition as action was not taken to monitor their weight.

People were not provided with consistently kind and caring support and they could not always be assured that they would receive support that was based upon their individual interests and preferences.

People could not be assured that they would receive the support they required as care plans did not all contain accurate, up to date information about people’s needs. People were not always offered the opportunity to be involved in the planning or reviewing of their care plans.

People were encouraged to be as independent as possible and staff treated people with dignity and respected their right to privacy. People were given opportunities to get involved in social activity and were supported to maintain relationships with family and friends.

There was a continued lack of appropriate governance and leadership and this resulted in us finding ongoing breaches in regulation and negative outcomes for people who used the service. Systems in place to monitor and improve the quality of the service were not effective and timely action was not taken in response to known issues.

People who used the service and staff had limited opportunities to give their views on how the service was run. Despite this people and staff felt able to share concerns with the management. There were systems in place to respond to complaints.

The management team were responsive to feedback and developed an action plan in response to the most significant concerns identified during this inspection.

Given the issues identified above the overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We carried out an unannounced comprehensive inspection of this service on 25 and 27 November 2014. Breaches of legal requirements were found in relation to the care, treatment and safety of people, consent, nutrition and hydration and governance. We conducted this inspection to follow up on breaches identified in our November 2014 inspection and to look at the overall quality of the service.

There was no registered manager for the service at the time of our visit and there had not been one in place since June 2016. A new manager had recently been appointed however they had not yet started in post, on the day of our visit there was a new acting manager in place. 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.

During this inspection we found that although people felt safe in the service, people were not always protected from the risk of abuse and information of concern was not always acted upon or shared with the local authority swiftly. Risks in relation to people's care were not always planned for appropriately to ensure people received safe care and support. Safe recruitment practices were not always followed.

Medicines were not always stored or managed safely. There were not always enough staff to provide care and support. People were supported by staff who had not received adequate levels of training.

People could not be assured that they would be provided with effective support in relation to their nutrition and hydration. People had their day to day healthcare needs met but where people had health conditions they could not always be assured that they would receive effective support.

People were supported to make day to day decisions but where people lacked capacity their rights under the Mental Capacity Act 2015 were not respected.

People were not always treated with dignity and their right to privacy was not always respected. Staff were caring and had positive relationships with people using the service. People were supported to make choices about how they spent their day. People had the opportunity to get involved in activities in the home but these were not always based upon people’s interests and hobbies.

People’s care plans did not provide a detailed description of people’s individual needs and preferences and did not contain all the relevant information to enable staff to provide effective support. People and their families were involved in the development of their care plans but were not involved in care plan reviews.

There was a lack of effective governance from the provider which put people at risk of receiving poor care. Quality assurance systems were not effective in identifying areas for development and action plans were not consistently developed or implemented. People and staff were not involved the development and running of the service.

The management team, led by the new acting manager, were approachable and open. People using the service felt able to share any concerns with the management knew how to raise concerns. Complaints and concerns were responded to appropriately. Staff were given feedback on their practice in supervision and they felt comfortable discussing issues, concerns and ideas with the management team.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to safe care and treatment, staffing, consent and good governance. We also found a breach of the Care Quality Commission (Registration) Regulations in relation to notifications that the provider is required to make to the CQC. You can see what action we told the provider to take at the back of the full version of the report.

The inspection team who carried out this inspection consisted of one inspector and a pharmacy inspector to answer five key questions; is the service safe, effective, caring, responsive and well-led.'

Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found people's care and support was planned and delivered in a way that ensured their safety and welfare, although we found that the service was not safe because people were not protected against the risks associated with the use and management of medicines. People did not always receive their medicines and nutritional supplements they needed. Some 'creams' were not kept in a safe way. Some medicines were not disposed of appropriately after their use by date. A person who used the service told us their support with medicines was, 'Ideal, but I'm taking a lot of tablets and I have asked staff several times (about their medicines and pain control) and nothing's happened for my pain'.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

We found the provider did not have effective systems to involve people in planning their care, and obtaining people's consent for this to be provided. A person who used the service told us, 'I haven't had anyone talk to me about my care plan. I would like someone to talk to me about it.'

We found staff were effective at meeting the care and welfare needs of people who used the service. A person who used the service told us, 'I feel absolutely safe in here. Staff are here to help you do the best you can.'

Is the service caring?

We saw staff respond to people in a sensitive and caring manner. A person who used the service told us, 'They do everything I want, I wish I could help them a bit. They are very good to me.'

Is the service responsive?

We found care workers responded appropriately when people had the capacity to make decisions about their care and welfare. A person who used the service told us, 'I do exactly what I would do if I was in my own flat, I feel confident in here.'

We found staff responded appropriately to the care and welfare needs of people who used the service. We saw the correct procedures had been followed when a person had fallen the previous evening.

There were sufficient care workers to respond to people's health and welfare needs. A person who spent a lot of time in their room told us, 'There is always someone here if I press the buzzer, they will be here in five minutes.'

Is the service well-led

Staff told us the manager provided good leadership, although they commented they seemed to have a lot they had to do. The area manager described the manager as, 'A good manager, but needs to delegate more.' A person who used the service told us, 'I think this is very well run.'

A member of staff told us, 'It is a lovely home to work in. (Name) is a really good manager. It is a pleasure to come to work. There is a lot of teamwork here.'

People we spoke with told us they were happy at the care home. Comments included, 'I like it, I have everything I need here and everybody is nice to me.' A visitor told us, 'My relative is definitely safe.' A member of staff told us, 'It is well led here and the manager is approachable, supportive and is always checking that staff are alright.'

The care plans examined showed that reviews of care and associated risks were not completed and reviewed in a timely manner.

We asked people who used the service if they felt that their safety and wellbeing was promoted. They told us they did, comments included, 'Yes, I have my call bell if I need anyone, everybody and the building make me feel safe.'

Some staff and visitors we spoke with thought that there were not enough staff employed by the home to deliver an appropriate standard of care. Comments included, 'The home is always understaffed and struggles to get gaps in the rota filled by carers who were on their days off.'

We saw that regular health and safety audits were undertaken. These included regular testing of fire alarms and that information from these was used to ensure that the environment was safe.