Bowerswood House Residential Home Limited was inspected on the 20 and 26 September 2018 and the first day of the inspection was unannounced.

Bowerswood House Residential Home Limited is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home is a large country house set in its own grounds and offers residential support to older people. Bowerswood House Residential Home Limited can support up to 24 people in mostly single en suite bedrooms. Rooms are on ground or first floor levels with lift access. There are large communal areas including two lounges and a dining room. There are gardens with raised beds for people to access if they wish. The home is a short drive from the town of Garstang.

At our last inspection in June 2016 the service was rated as ‘Requires improvement’. We identified a breach of Regulation 12 of the Health and Social Act Care Act 2008 (Regulated Activities) Regulations 2014. We found people could not be assured that medicines were managed safely. We took regulatory action and served a warning notice for this breach in regulation.

At this inspection in September 2018 we found medicines management had improved but further improvements were required to ensure that medicines were managed safely. For example, records did not always inform staff of the support people required in relation to their creams and records were not consistently completed accurately. This was a breach of Regulation 12 of the Health and Social Act Care Act 2008 (Regulated Activities) Regulations 2014.

We looked at the arrangements in place for the prevention of infection. We saw a bathroom required attention as it was not visibly clean, clean laundry was stored in open baskets where soiled laundry was washed, and hand washing facilities did not minimise the risk and spread of infection. This was a breach of the Regulation 12 of the Health and Social Act Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection in September 2018 we found records in relation to the management of the home and a staff recruitment record, were not complete. We also found audits had not identified the concerns we had identified in relation to the safe management of medicines and the prevention of infection. This was a breach of Regulation 17 of the Health and Social Act Care Act 2008 (Regulated Activities) Regulations 2014.

You can see the action we told the provider to take in the full version of the report.

Care records contained information regarding risks and guidance for staff on how risks were to be managed. We found two care records required updating as further information was required regarding the needs of the people they related to. We also viewed food charts relating to two individuals in the home and saw these did not specify the amount of food people had eaten. We have made a recommendation about the recording of care and nutritional information.

Staff told us they were recruited safety, received regular training activities and they felt supported by the registered manager. Staff told us they had supervision and meetings to discuss their training needs and any concerns they had. We noted some meetings with staff were recorded informally. We have made a recommendation regarding the recording of staff meetings.

We found some information was recorded regarding people’s end of life wishes and the deputy manager and registered manager told us they were planning to seek further guidance regarding the documentation of people’s end of life wishes. We have made a recommendation regarding end of life care planning.

At the time of the inspection visit there was a manager in place who was registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the s

This comprehensive inspection was carried out on the 28 June 2017 and the 05 July 2017. The inspection was unannounced.

Bowerswood House is a large country house set in its own grounds. The home offers residential support to older people. The home can support up to 24 people in mostly single en suite bedrooms. Rooms are on ground or first floor levels with lift access. There are large communal areas including two lounges and a dining room. The home is a short drive from the town of Garstang.

At the time of the inspection visit there was a manager in place who was registered with the Care Quality Commission. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We last inspected Bowerswood House in October 2015. The registered provider did not meet the requirements of the regulations during that inspection as multiple breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. Breaches were identified in good governance, consent to care and treatment, staffing and safe care and treatment.

Following the inspection the registered provider sent us an action plan detailing how they would achieve compliance with the regulations. At this inspection visit we checked to see if they had followed their plan and found some improvements had been made.

During this inspection visit carried out in June 2017 we found good practice guidelines were not consistently followed to ensure people received their medicines safely. We found medicines were not always stored safely and medicine records were not always accurate. In addition we found one person was managing their own medicine but we found the records and care planning about this were not accurate. We saw medicines were sometimes administered without consideration for people’s dignity and checks in place had not identified the improvements required in the safe management of medicines. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Safe care and treatment.)

At this inspection we found some improvements had been made. We found staff had access to a range of refresher training to enable them to update their skills. This included training in moving and handling, safeguarding, the Mental Capacity Act and Deprivation of Liberty training. Staff told us they received supervision and they could approach the registered manager or the deputy manager if they wanted clarity or had any concerns.

We found improvements had been made to the environment. We saw window restrictors had been fitted to windows, PEEPS were in place and fire doors were closed.

The registered manager carried out checks to ensure improvements could be identified. These included checks on care records, attendance at training and accidents and incidents. There was a quality survey in place, which was provided to people who lived at the home. This enabled people to give feedback on the service provided.

We reviewed documentation which described the care and support people required. The documentation we viewed contained the social histories and interests of people who lived at the home. We saw if people required advice from other health professionals, referrals were made appropriately.

We observed care and support being provided in a safe way and people told us they felt safe. One person told us, “I feel very safe here.”

Staff were able to explain the actions they would take if they were concerned someone was at risk of harm or abuse. They told us they would report concerns to the registered manager, the Care Quality Commission or the Lancashire Safeguarding Authorities so further investigations could take p

Bowerswood House is a large country house set in its own grounds. The home offers residential support to older people. The home can support up to 24 people in mostly single en suite bedrooms. Rooms are on ground or first floor levels with lift access. There are large communal areas including two lounges and a dining room. Gardens are accessible to all with raised beds for residents to grow their own flowers and vegetables if they wish. The home is a short drive from the town of Garstang.

The service has a registered manager; however, they were on holiday at the time of our visit. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run. The deputy manager and administrator supported us during our inspection visit.

Care plans were personalised and contained people’s preferences on how they wanted to be supported and cared for. Care plans were evaluated and reviewed regularly and people and their relatives told us they were included in developing plans if they chose to do so. Staffing levels were such that staff were able to spend quality time with people engaging and chatting in a warm and compassionate manner. People’s nutritional and dietary requirements were met, with referrals being made to dietitians and health care professionals if needed. Staff had a warm and caring approach with people and we observed relationships which were respectfully affectionate and mutual. People and their relatives said they had no concerns or complaints but knew who to speak to should they have any worries.

Under current fire safety legislation it is the responsibility of the registered manager to provide a fire safety risk assessment that includes an emergency evacuation plan for all people likely to be on the premises in the event of a fire. In order to comply with this legislation, a Personal Emergency Evacuation Plan (PEEP) needs to be drawn up for each individual living at the home. Information held within the care records showed that PEEPS had not been completed. We also noted that a number of designated fire doors were either wedged open or propped open. We reviewed the house’s fire risk assessments, and found that this practice was contrary to that detailed within the document. The deputy manager agreed to remove the wedges, and said that an alternative and safer way to keep fire doors open would be explored. On touring the home, we found a number of windows that did not have restrictors fitted. The registered manager needed to update their risk assessment regarding windows and their restrictors. Where assessments identify that people using the service are at risk of falling from windows or balconies at a height and likely to cause harm, suitable precautions must be taken. Windows that are large enough to allow people to fall out should be restrained sufficiently to prevent such falls. We found a number of windows that did not have restrictors fitted.

We noted that one person living at the used a machine that supplied them with oxygen. We reviewed the care file for this person, and found that they did not have a specific risk assessment regarding the use of his machine. A procedure should be in place for informing the emergency services of the location of oxygen if they are required to attend in the event of a fire or fire alarm.

We checked the medicines administration record (MAR) for one person. We found that the staff had recorded that this person had refused a specific medicine; however, we noted that the medicine was not in stock. The deputy manager explained that the person was no longer prescribed this medicine. This had not been properly recorded on the person’s MAR. We also found further errors in recording with some staff signatures missing on the MAR, and one signature written in the wrong place on the MAR.

The staff we spoke with understood the need to ensure people were enabled to give consent to care, and understood the requirement to seek external advice and guidance if there were any doubts about a person’s ability to make informed decisions. However, we questioned if the care plans and assessments were always followed. This was in particular referrence to the administration of PRN medicines for pain relief, and people’s right to refuse medicine if deemed to have the capacity to do so.

The deputy manager explained that the service had a training programme for staff to follow, however, this was found to be very limited, with staff being provided with basic mandatory training when they first started work at the home. Staff with particular roles within the home, such as the administration of medicines, were provided with further training. The staff told us they did not always receive update training as required. One staff member told us that they had not received any update training on any subject in the last 12 months, even though their training records showed that they needed these updates. The records showed that there were gaps in the staff training updates; however, there was an action plan in place to address this. The deputy manager explained that supervision arrangements were in place; however, these were not routinely followed. The staff we spoke with said that they did not receive formal supervision during which they could discuss their role and work, and identify their learning and development needs.

We found written evidence to show that the service had a system in place to assess and monitor the quality of the service. The deputy manager and administrator explained that they were involved in auditing different aspects of the service provided. We saw evidence of these audits, and saw that the system had flagged up areas of concern, and minor issues relating to care delivery and service provision. However, these audits had not identified discrepancies in the medicine administration records, recruitment files, environmental risks, fire risks and supervision records.

We recommend that the service provider and registered manager consults and follows the NICE guidance on the safe administration of medicines in order to ensure that a consistent approach is maintained by staff at service. This would ensure medicines are handled and administered safely, and ensure people’s well-being and best interests are promoted and protected.

We recommend that the service provider and registered manager consults the NICE guidance on participation in meaningful activity in care homes and that discussions take place with people at the home regarding the development of the activities programme.

We identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

This inspection was scheduled to follow up the areas of non-compliance identified at our inspection of this service in April 2013. When we visited the home in April we found non-compliance in the areas of consent to care and treatment, meeting nutritional needs and monitoring the quality of service delivery.

We visited the home on 5th November 2013 and found that the provider had made the necessary improvements to achieve compliance.

People told us they were able to consent to their care and treatment and we saw the home had assessed people when they had concerns about their capacity. One person told us, “I like to be left in peace and this is our agreement and understanding. They are very nice people (staff) who respect my wishes”.

We saw that the home had revised the menu in consultation with people living at the home and had made suitable arrangements for the storage of food products.

We saw that monitoring quality had improved and the provider had recognised that they could still improve the quality assurance process.

We spoke with people who lived at the home about how they gave their consent. One person said, “I am asked everyday what I want to wear and if things that are done for me are ok.”

Relatives and people living in the home we spoke with said they felt safe and had confidence in the staff. One relative said, “My mother has been here for four years and I wouldn’t leave her here if I wasn’t happy with how she is treated.”

We spoke with people living at the home about the food provided and its nutritional standards. People seemed generally happy with the standard of the food but were unsure about the choices they were offered. One person said, “I get asked if I want what is offered, if I decline I can always have an egg.”

We spoke to people living in the home about the suitability of staff. Everyone we spoke with said the staff were very nice. One person said, “The staff do very well taking good care of us all.”

The home did not have a standard quality monitoring system. We were not given any evidence to support the home had undertaken appropriate assessment of health and safety including risks associated with the kitchen.

We spoke with three people about medicines handling at the home. They confirmed that they were happy for care workers to administer their medicines.

One person confirmed that care workers applied their creams as needed. A second person told us they were able to tell staff what pain relief they needed.

People spoken with confirmed that staff respected their wishes and took into account their individual wishes and choices. Comments included, ‘I am asked what I would like to do and can make decisions about when I would like to go to bed or whether I stay in my room during the day.’ One person was looking forward to being taken out to a garden centre by staff and apparently this is a regular outing. Others were discussing the arrangements for the next day as the home was planning a special buffet in honour of the Royal Wedding. Everyone was going to dress up in red, white and blue clothes and they had been making crowns. Apparently relatives and friends and staff families had also been invited and there was great excitement about the whole event.

With regard to the assistance provided by staff, a number of people spoken with confirmed that they were very happy at the home and had been living there for a number of years. Staff were attentive and there was a very friendly atmosphere. They had ‘no complaints’ and were encouraged to be as independent as possible.

Two people spoken with commented on the meals and food provided. ‘Meals are excellent, we get plenty and there is a choice provided.’ One person who had only recently moved into the home stated how nice it as to have the meals provided after being on her own and she had no complaints.

Staff are very attentive and any requirements they had were met straight away when they called for attention. The people spoken with related better to some staff than others but it was not because staff were not capable but, by the age or maturity of the staff member concerned.

People were very complimentary about the service provided. Family and friends are very much part of the home and encouraged to participate and this ensures one big happy family. If there were any concerns, people spoken with confirmed that they knew who to approach and staff had taken notice of them when they were unhappy about anything and action had been taken.

People told us they were involved in their admission and that they made decisions about their care and how they lived their lives. One person said they had visited the service to look around before deciding to stay and another said their family visited the home on their behalf. One person said, “I was very ill at the time, I had to move and it was a good choice. I’m much better and I love my bedroom. I have beautiful views".

People told us the staff talked to them about their care and support needs. This usually involved discussions about how they wanted their personal care to be provided or how they wished to spend their day.

People told us they received support from staff to remain independent and well. One person said, “I couldn’t walk when I came here. With help from the staff I can walk better. I’m hard work but they have been patient and encouraged me”.

People told us they experienced care and support that met their needs and protected their rights. People said that they had access to a local general practitioner and NHS services. A person said, “I saw my doctor recently as I wasn’t well. I had a problem swallowing. They (staff) called the doctor and they are keeping an eye on me. They will call the doctor when I need”.

People told us that there were plenty of opportunities for social and recreational activities. We saw people playing dominoes together and we were told people played dominoes and other similar games each week. One person said, “We do this every week but I don’t always join in”.

We were told staff treated people well and they had no cause for concern. We were told they had no rigid routines they had to follow and generally could do what they wanted.

People told us that they had chosen their bedrooms and were able to bring a selection of their own furniture.

People told us that staff were patient and encouraged them to remain independent and maintain their health. A person said, “I’ve had strokes, so can’t do much with my arms. Staff understand what I can do. When I get dressed they (staff) say you do what you can then help me when I’m struggling”.

People told us the home was well managed. They said that staff respected their decisions and choices. We were told that the provider had built raised flower beds so people could grow flowers and vegetables as a result of requests from people living at the home.