Bushmead Court Management Limited received a Good rating across all five key questions at its December 2015 inspection, demonstrating safe, person-centred care delivered by a well-trained and compassionate staff team within an extra care housing scheme. The sole area identified for improvement was the inconsistent formal documentation of staff supervision, which the registered manager acknowledged and committed to address.
Concerns (1)
minor
Supervision / appraisal
: “there was not always evidence of regular formal supervision in the staff records we looked at. The manager acknowledged that this was an area they needed to improve on.”
Strengths
· Sufficient staffing levels with staff based on-site ensuring timely support and no late visits
· Medicines managed safely with completed MAR records, secure storage and no unexplained gaps
· Effective safeguarding policies, whistleblowing procedures and up-to-date staff training
· Staff demonstrated exceptional caring attitudes, going above and beyond care plan requirements
· Person-centred care plans regularly reviewed and updated to reflect changing needs
Bushmead Court Management Limited provides broadly good, person-centred homecare with safe, well-trained staff and positive outcomes for people. The Well-led rating was limited to Requires Improvement solely because the outgoing registered manager had not de-registered with CQC and the incoming manager had not yet registered, alongside minor gaps in supervision frequency and survey collation.
Concerns (6)
criticalGovernance: “The previous registered manager had left their job role in July 2018 and had not de-registered with the Care Quality Commission. The current manager...had not registered with the CQC.”
moderateCare planning: “People with specific needs such as dementia or diabetes did not have thorough risk assessments covering how staff should support them in these areas.”
moderateSupervision / appraisal: “Formal staff supervision was not being carried out regularly. The manager told us that they were looking to improve the frequency of these.”
minorMedication management: “Topical medicines such as creams were being administered by staff members and were being signed on MAR charts as 'administered by staff'. This was not best practice.”
minorGovernance: “People had been asked for feedback in surveys carried out in August 2018. The manager told us that they had not had time to collate the information from this survey yet.”
minorConsent / capacity: “Where necessary, capacity assessments had been completed in line with guidance. Though these were recorded correctly it was unclear how decisions had been reached in some cases.”
Strengths
· People felt safe and were protected from harm; robust safeguarding policies and staff training in place.
· Consistent, timely care visits with sufficient staffing levels and reliable duty manager cover.
· Staff were well-trained, knowledgeable and received thorough inductions.
· People were treated with kindness, dignity and respect, and involved in their own care planning.
· Personalised, person-centred care tailored to individual preferences, cultural and religious beliefs.
Quality-Statement breakdown (23)
safe: Systems and processes to safeguard people from the risk of abuseGood
safe: Assessing risk, safety monitoring and managementGood
safe: Staffing and recruitmentGood
safe: Using medicines safelyGood
safe: Preventing and controlling infectionGood
safe: Learning lessons when things go wrongGood
effective: Assessing people's needs and choices; delivering care in line with standards, guidance and the lawGood
effective: Staff support: induction, training, skills and experienceGood
effective: Supporting people to eat and drink enough to maintain a balanced dietGood
effective: Staff working with other agencies to provide consistent, effective, timely careGood
effective: Adapting service, design, decoration to meet people's needsGood
effective: Ensuring consent to care and treatment in line with law and guidanceGood
caring: Ensuring people are well treated and supported; equality and diversityGood
caring: Supporting people to express their views and be involved in making decisions about their careGood
caring: Respecting and promoting people's privacy, dignity and independenceGood
responsive: Planning personalised care to meet people's needs, preferences, interests and give them choice and controlGood
responsive: Improving care quality in response to complaints or concernsGood
responsive: End of life care and supportGood
well-led: Managers and staff being clear about their roles, and understanding quality performance, risks and regulatory requirementsRequires improvement
well-led: Engaging and involving people using the service, the public and staff, fully considering their equality characteristicsRequires improvement
well-led: Planning and promoting person-centred, high-quality care and support; and how the provider understands and acts on duty of candour responsibilityGood
well-led: Continuous learning and improving careGood