Bearwood House Residential 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 found a breach of the legal regulations relating to the governance of the service. There was not an effective system in place to monitor the service. Audits were either not effectively in place or they were not robust enough to ensure actions were identified and improvements were made. People's records were not always accurate and up to date and did not contain person-centred information about people's needs. Senior care staff did not have access to all documents to update changes in people’s needs or risks or the level of monitoring they required. However, the provider had started to make some improvements to the culture of the service to ensure staff felt able to report their concerns and the improved visibility of the covering manager. We have asked the provider for an action plan in response to the concerns found at this assessment.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The covering manager informed us of the planned move of the location of the manager office, as this was currently in a separate building to the care home. The covering manager told us they planned on moving the office upstairs in the care home to ensure more visibility, access and oversight for people, relatives and visitors and staff. Staff we spoke with confirmed the culture of the service had improved recently, and they felt supported from the covering manager and nominated individual. Staff commented on the visibility of the covering manager and their efforts to come into the home and speak with people and staff.

The provider kept records of any actions identified and required to improve the service on their service improvement plan, there was limited audits provided to establish how the actions for improvement had been identified. The nominated individual informed us they did not always document when completing checks or audits of the service. The covering manager also confirmed some audits were completed by the area manager and these were not accessible at the time of the inspection.

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.

Staff we spoke with were complimentary of the covering manager and confirmed positive changes had been noticed recently. Staff felt able to approach and raise concerns with the covering manager and they confirmed the culture and atmosphere in the home was more positive since the covering manager had been in post. One member of staff told us, “I can share concerns with the senior or the management, and action is taken when things are raised.” One member of staff confirmed “The service is being ran well, everyone is relaxed, and we are free to talk to the manager now. The manager always comes in to see if everyone is alright, they are just so supportive in everything.” One member of staff told us, “We have felt on edge previously, that atmosphere has gone now under the new manager, they have made themselves known to the staff and residents, it works better, you can approach them if you need to”.

We reviewed the numbers of staff who completed supervisions and staff we spoke with confirmed they had regular supervisions which were of a benefit. Following recent concerns shared to us by staff members, the operations manager had completed staff supervisions, to ascertain any concerns and take required action. At the time of the inspection the operations manager was not available and therefore we were not aware of the action taken in response to the supervisions. The nominated individual confirmed concerns had been raised by staff, however, they did not take action to investigate these concerns until we made them aware of similar concerns raised directly to us.

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 we spoke with felt the service was being ran well. Staff confirmed they felt able to raise concerns or suggestions and things would be done differently. One member of staff told us, “the most important thing is that residents needs are being met and I feel that is the case”. Another staff member told us, “I have no concerns, it is moving in the right direction, no concerns whatsoever.” However, we found staff feedback had not always been acted on in a timely manner.

We found staff were contacting external support for an identified need for one person. Staff were not aware of information contained within their person’s care plan relating to 1:1 support due to this same identified need. When raised the covering manager took action to review these records and source required support for this person. Their care plan was also updated to reflect the current assessed need. The provider was in the process of making improvements to their systems to ensure action was identified and taken following identified improvements. The systems currently in place to monitor and audit the service were not robust enough to ensure improvements could be identified and made. The covering manager had identified where audits had not been completed and had started to audit the service, we found however, there was limited provider audits in place to review the audits completed by the previous registered manager. The systems in place to audit and make improvements to the service had not identified where further action was required for staff to follow in response to when people had not had a bowel movement following the PRN laxative. The systems in place had not identified where people were being monitored when this was not required. There was no audit in place to ensure new staff members had required recruitment checks in place.

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.

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