Bluebell Manor

Updated 24 June 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

This inspection was undertaken by three inspectors and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

East Riding Care Home is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. East Riding Care Home is a care home with nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed the information we held about the service, including the statutory notifications we had received from the provider. Statutory notifications are reports about changes, events or incidents the provider is legally obliged to send to us. We contacted the local authority commissioning and safeguarding teams, the local NHS infection prevention and control [IPC] team, fire service, Integrated Care Board and Healthwatch to request feedback. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England.

We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people who used the service and 9 relatives about their experience of the care provided. We spoke with 13 members of staff including the registered manager, deputy manager, care staff, nursing staff, administrator, housekeeper and chef. In addition, we received feedback from 1 visiting healthcare professional.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We reviewed a range of records, this included care records for 12 people including medicines records. We looked at the recruitment records for 3 staff and a variety of records relating to the management of the service, including policies and procedures. Following the inspection site visits we requested additional information by email and continued to seek clarification from the provider to validate the evidence we found.

Updated 24 June 2023

About the service

East Riding Care Home provides accommodation, personal and nursing care for up to 67 people; some of whom are living with a dementia related condition. At the time of the inspection there were 37 people living at the home. Support is provided across 2 floors in 3 units which have been adapted to meet people's needs.

People’s experience of using this service and what we found

Action had been taken following the last inspection to deliver improvements. However, we identified on-going issues with the management of medicines and the oversight of this. Governance systems had improved but more work was required to ensure medicines audits were effective in identifying issues to enable staff to take the appropriate action to make sure medicines were managed safely.

The registered manager worked in an open and transparent way and understood their responsibilities in relation to the duty of candour regulation. Appropriate documentation was in place in response to any notifiable safety incident.

Policies and procedures in relation to infection prevention and control (IPC) to prevent the spread of infections were in place. Arrangements were in place to support people to maintain contact with people important to them. This included indoor visits from relatives or friends and supporting people to maintain contact using technology.

Systems were in place to review incidents to assess if any improvements to staff practice could be made. Safe recruitment procedures had been followed and there were enough staff deployed to meet people’s needs. Systems were in place to safeguard people from the risk of abuse and the risks people were exposed to had been assessed.

Staff received training which the provider had assessed as mandatory and staff told us they felt supported in their job role. Staff were positive about the registered manager and told us East Riding Care Home was a nice place to work. One member of staff told us, “[Name of registered manager] is interested, she's involved, she helps, and she will stay and cover. It makes people feel better when you know she will do what we are expected to do.”

Staff were kind and spoke fondly about their relationships with people. They described situations where they had gone out of their way to provide person-centred support for people. One staff member said, “I can see the difference from when I first started. It's nice to see the residents with a smile on their face. I feel proud to work here and to make the home a nice, pleasant place for residents to live in.”

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Best interest’s decisions were completed for people who could not consent to their care and treatment in line with legal requirements.

People’s communication needs were met. Information was available to people in alternative formats to support people’s communication needs. End of life care plans were in place to ensure any wishes people had for their end of life care were recorded. Staff provided care and support which was person-centred to the individual needs of people. Systems were in place to investigate and respond to any complaints and to acknowledge any compliments.

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 inadequate (published 21 November 2022) and there were 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 some improvements had been made. However, the provider remained in breach of regulations.

This service has been in Special Measures since 17 November 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We carried out an unannounced comprehensive inspection of this service on 13 September 2022. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person-centred care, dignity and respect, safe care and treatment, safeguarding, nutrition and hydration, good governance, staffing, safe recruitment, duty of candour and notification of incidents.

We undertook this comprehensive inspection to check they had followed their action plan and to confirm they now met legal requirements.

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 monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.