Bowerfield House

On this page

• 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

The service had not always been well led. At the time of the assessment there was a new management team in post who were working to drive improvements. There had not been consistent oversight of the service since our last inspection with shortfalls found in the oversight of environmental safety and record keeping. Processes for analysis and oversight needed further work to ensure they were embedded and effective. There continued to be a breach of good governance meaning that people were not always protected from potential risk and, improvements were not always effectively made to ensure the safety and quality of the service. However, people, families and staff spoke positively about some of the recent changes being made.

This service scored 57 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff spoke positively about the new manager and were encouraged by the stability the new management team had brought. However, staff were concerned about the numerous and frequent changes of manager and the impact changes of management have upon the smooth running of the service, changes in processes and expectations of them.

There were processes in place to ensure a shared direction between the provider, staff and the people using the service. There was a new management and area management team and the processes recently introduced needed to be embedded to ensure they led to change and improvements being made. Changes were not always made as quickly as people wished. For example, a family member had raised a concern about lack of activities for their family member over a month prior to our visit and had been reassured by the provider that a new activity worker was due to start. However, there was no activity worker in post at the time of our visit.

Staff spoke highly of the new manager. They told us the changes of management had made things difficult, with new managers bringing in different ideas. The manager of the home was committed to working at the home long term and driving improvement and providing consistency and stability for both the people living at the service and the staff team. Staff felt the impact of the management changes had been detrimental to the service and worried about the possibility of further changes within the management team but were hopeful for the future.

Processes were in place to discuss concerns. However, not all processes were fully embedded to ensure changed were made and developed. For example, the provision of personal care has been discussed with staff within team meetings but at the time of our visit some shortfalls in these areas were identified. The management team did not always have access to information that was accurate and up to date. For example, information in relation to staff competencies and supervision was only updated following our initial site visit and review of this information. The management team needed further time to embed and develop effective practice and leadership within the home.

Staff felt able to raise concerns and felt the manager would take action where needed.

Surveys and meetings were in place but the responses to surveys and attendance levels at relatives’ meetings was low, making it difficult to obtain the views of people and their families. It was not clear that the provider had considered other ways to ensure people families and staff all felt able to be involved and share their views.

Staff were employed from a wide variety of background and felt that their diversity was respected and valued.

The provider had suitable processes in place to ensure staff were treated well and equality and diversity was valued.

The manager completed various audits and systems for oversight. The management team felt this was supporting the improvements needed within the home but recognised this work was ongoing.

There was a new manager and management team in place. At the time of inspection, it was not evident there was sufficient oversight of all aspects of the service. For example, whilst there were care plan audits, these were not identifying areas for improvement, and the lack of records in relation to health and safety meant there was not clear oversight and important checks had been missed.

People felt staff worked with other services to meet their needs. Some people commented they would like more activities and engagement with the local community to improve their wellbeing.

Staff felt that the staff team worked well together and told us they had good working relationships with other agencies.

Partner agencies fed back that staff worked well with them to meet people’s needs.

There were processes in place to support oversight of people’s needs and ensure appropriate referrals were made where needed. At the time of the inspection there was a new management team and evidence that the processes for good partnership working needed embedding further. There was no activity worker in post at the time of our visit and some of the connections with the community needed reinstating and developing.

Staff felt the service had started the process to make improvements. Staff told us there were areas for improvement including the premises and activities available for people. The manager had begun to create the stability needed to drive improvement across the home and staff spoke positively about this.

The provider had processes in place to ensure learning and to drive improvement. However, this had not been fully embedded into practice at the time of the inspection. Records indicated lesson learnt were being shared, for example, a meeting to discuss the importance of accurate and contemporaneous records and encouraging fluids had been held. However, the required action had not been consistently embedded at the time of inspection as we found shortfalls in how people were supported to access fluids at night. A relatives’ meeting referenced discussion about developing a sensory room, improvements being needed in regard to activities and the tired décor of the home four months before our visit but these matters were still ongoing at the time of inspection.