Bishop's Cleeve Care Home

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We identified one continued breach of the legal regulations in relation to good governance. We found the provider’s oversight of the actions taken to improve the service had not been sufficient or effective in supporting the interim manager to address the breaches of regulations and the issues raised in the warning notices issued at our last inspection. The interim manager had been diligent in addressing the shortfalls including recruiting and training a permanent staff team and developing systems to monitor the quality of people’s care. However, they had not had the capacity to completely embed the systems required to fully meet the breach of regulations. Further time and support was needed to prioritise people’s safety while the interim manager worked on their action plan and audit findings to improve the service. Plans were in place to ensure staff were suitably trained and competent to support people’s safely and to follow the provider’s policies and procedures. We found some improvements had been to the management of people’s care. Since being in post, the interim manager had implemented several systems to assist them in the monitoring of people’s risks and care needs. This enabled them to have an enhanced oversight of people’s known and emerging risks, including accidents and incidents and to be able to take appropriate action.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff stated they had started to see some improvements being made to the home’s systems such as regular meetings which helped to share relevant information about people’s care and the running of the home. The interim manager identified more improvement was needed in implementing and embedding the providers' quality assessment frameworks to help the management team monitor the service. They told us they were working and supporting staff to be competent in their role and to understand people’s individual support needs.

Since our last inspection, the provider had not dedicated adequate resources to support the management of Bishops Cleeve Care Home to address the areas of non-compliance. This placed people at continual risk. The provider had a range of scheduled audits and systems designed to assess and record their compliance with legislation and best practice. For example, accident and incident reports were regularly reveiwed and discussed with the staff team and clinical risk meetings were being held to discuss people’s known and emerging risks. However, more time was needed for these audits and systems to be consistently effective. For example, fire drills were not being completed in line with the provider’s fire policy and risk assessment. Information sharing, about people’s dietary risks and needs, with kitchen staff was not always consistent. For example, kitchen staff were not aware that 1 person had recently been losing weight and needed adjustments to their diet to help regain weight. Some relatives shared they had concerns about the level of communication from the staff and provider and told us, for example, they often did not receive a response from the staff or the provider.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The interim manager was responsive to our assessment feedback about the inconsistencies in the management of people’s thickened fluids. They had contacted the speech and language therapy team and the GP to confirm the correct level of thickener to be used for people. In addition, they had implemented face to face training for the day and night staff to be shown how to correctly make people’s drinks, using the prescribed thickener, according to their needs. The interim manager had introduced various systems to enable them to observe staff practice, share information, support staff and reflect on any incidents. These systems had helped to mitigate risks while further improvements were being made, including supporting staff to improve their practice. For example, the management team conducted ‘home walk arounds’ 3 to 4 times per week to help them monitor the quality and delivery of care being provided to people and the safety of the building. We saw evidence that lessons learnt were being shared with senior staff during the daily huddle meetings.

Staff told us they had opportunities to reflect on their practices and share good practices to achieve positive outcomes for people. The interim manager shared learning from incidents and debriefing staff enabled staff members to learn from each other and helped to prevent other incidents.