1 July 2021
During an inspection looking at part of the service
Bournbrook Manor Home Ltd is a residential care home providing personal care to 19 younger and older people at the time of the inspection. The service can support up to 23 people.
People’s experience of using this service and what we found
During the last inspection concerns were identified with the management of the home. During this inspection we found similar and additional concerns. The management team did not have the skills, knowledge and experience to ensure people’s needs were identified and assessed.
People’s known risks were not identified, assessed and mitigated, this included risks associated with choking. There was insufficient guidance for staff to follow if a person were to have a seizure. The provider’s systems and processes to ensure known risks to people were assessed and mitigated were inadequate. This placed people at immediate risk of harm. Despite our findings people told us they felt safe.
Fire safety measures were not adequate to keep people safe. The provider’s systems and processes to assess and mitigate fire risks had failed. We were not assured infection prevention control measures were safe and protected people from the risks associated with COVID-19. The provider’s systems had not identified the government guidance around COVID-19 was not being followed.
It is a legal requirement for the provider to display the home’s Care Quality Commission (CQC) rating on their website and in the home, the provider had failed to do this. The provider failed to comply with conditions on their registration, this included not having a manager registered with CQC.
We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right Support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.
Based on our review of safe and well-led the service was not able to demonstrate how they were meeting the underpinning principles of right support, right care, right culture. Care plans were not person-centred to promote people’s dignity. The ethos, values, attitudes and behaviours of leaders could not enable staff to ensure people using services lead inclusive and empowered lives. We asked the provider to review everyone’s care plans to ensure people’s needs and areas of risks were identified, and sufficient planning and risk mitigation was in place.
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 19 March 2021) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found there were not sufficient improvements made and the provider was still in breach of regulations. This service had been rated requires improvement for the last three consecutive inspections, with this rating being inadequate.
Why we inspected
We received concerns in relation to risk management, an incident where a person had choked and infection control. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.
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 inadequate. This is based on the findings at this inspection.
We have found evidence that the provider needs to make improvement. Please see the safe and well-led sections of this full report. You can see what immediate action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bournbrook Manor Home Ltd on our website at www.cqc.org.uk.
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.
Enforcement
We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.
We have identified breaches in relation to safe care and treatment, governance, failure to have suitably skilled and qualified people employed, failure to comply with conditions of registration and failure to display ratings at this inspection.
Please see the action we have told the provider to take at the end of this 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.
Follow up
We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.
Special Measures
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.
If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.