Bourne Wood Manor Care Home

Updated 13 September 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 was carried out by 2 inspectors, 1 specialist nurse advisor and 1 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

Bourne Wood Manor Care Home 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. Bourne Wood Manor Care Home is a care home with nursing care. The Care Quality Commission (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.

The service had a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since its registration. We sought feedback from the local authority. 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 of this information to plan our inspection.

During the inspection

We spoke with 13 people who used the service and 4 relatives about their experience of the care provided. We received feedback from 5 healthcare professionals who recently engaged with the service. We spoke with 14 members of staff including the registered manager, the deputy home manager, the regional director, a registered nurse, the maintenance person, care staff and kitchen staff. We observed interactions between staff and people who used the service. We reviewed 13 people’s care records, 4 staff recruitment files, medicines management records, policies and governance records. We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

Updated 13 September 2023

About the service

Bourne Wood Manor Care Home is a care home registered to provide personal and nursing care for up to 64 people. The service provides support to people requiring care and people living with dementia. At the time of the inspection, there were 59 people living at the service, some of whom were living with dementia.

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

People and their relatives told us staff were kind and caring towards them and they felt safe living at Bourne Wood Manor Care Home.

Staff were aware of risks related to people’s care and how to support people appropriately. Staff knew how to whistleblow and raise concerns inside and outside of the organisation should they need to.

There were sufficient staff deployed to support people with their needs.

There were plans in place in the event of an emergency evacuation. Staff had completed individual personal emergency evacuation plans for people.

We were assured the service were following safe infection prevention and control procedures to keep people safe.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People, their relatives and staff told us they were given the opportunity to feed back on the service and attend meetings. Where the provider had identified areas of improvement in relation to people being able to access external healthcare professionals, the provider had plans in place to address this.

People, their relatives and staff told us there was generally a positive atmosphere at the service which engaged them. They told us that the service was managed effectively and generally spoke positively of the management of the service.

There were systems in place to monitor the quality of the service and make improvements where shortfalls were identified.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 24 November 2021).

Why we inspected

The inspection was prompted in part by concerns received about staff management of people’s risks following falls, strokes and other deteriorations, and the culture in the service. A decision was made for us to inspect and examine those risks. 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. We did not find evidence of the concerns we received prior to the inspection.

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 COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bourne Wood Manor Care Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.