Skip to content
CQC ExplainedEvery inspection report, in plain English

CQC report explained · a nursing home, run by AKD Care

Bank House Residential Care Home

Gosberton Bank, Gosberton, Spalding, PE11 4PB

Requires improvementpublished 29 February 2024, 2 years ago

Rated Requires improvement: inspectors found the service was not performing as well as it should and told it what to change.

The five questions inspectors ask
Safe?
Requires improvement
Risks were not always fully assessed or acted on. Medicines were not always managed safely, although there were enough staff and the home was clean and tidy.
Effective?
Requires improvement
The home did not always follow the Mental Capacity Act, and assessments did not always accurately reflect people's needs. Staff training and support with food, drink and healthcare were positive areas.
Caring?
Good
This question was not inspected during this visit, so the report gives no current rating.
Responsive?
Good
This question was not inspected during this visit, so the report gives no current rating.
Well-led?
Requires improvement
Management systems and audits were not effective enough to identify concerns and drive improvement. Records were not always kept clearly, and people, relatives and staff had not been asked for their views about the service.
The latest report, explained

What inspectors found, February 2024

Rated Requires Improvement; inspectors found concerns about risk assessments, medicines, people's rights and the home's oversight.

This was an unannounced inspection on 20 December 2023. Inspectors spoke with six people, staff and the registered manager, observed care, and checked care records, medicines records, staff files and management records.

The home was not always safe or effective. Risks were not fully assessed, some care plans conflicted, and medicines were not always given or recorded safely. The home had also not applied for Deprivation of Liberty Safeguards for everyone who needed them.

There were enough staff, staff had suitable training, the home was clean and people were supported with food, drink and healthcare. However, audits and records did not reliably identify problems or make sure they were fixed.

The overall rating changed from Good at the last inspection in 2018 to Requires Improvement. The inspection focused on Safe and Well-led, and was widened to include Effective after concerns about the Mental Capacity Act were found.

What inspectors praised

  • Clean home

    The home was clean and tidy, and staff followed infection prevention and control practices.

    “People were protected from the risk of infection as staff were following safe infection prevention and control practices.” from the report

  • Food and healthcare

    People were supported to eat and drink enough, and the home involved healthcare professionals when needed.

    “People were supported to eat and drink enough to maintain a balanced diet.” from the report

  • Learning from incidents

    The registered manager reviewed incidents and made referrals or changes when needed to help keep people safe.

    “The registered manager reviewed all the incidents to see if change in people's care could keep them safe.” from the report

  • Approachable staff

    People and staff described the registered manager and staff as kind, supportive and approachable.

    “People living at the home and relatives told us that the registered manager and staff were kind and approachable, and the service was well managed.” from the report
What inspectors were concerned about

  • Risks not fully assessed

    serious

    Care plans did not always identify people's needs, equipment or risks. Some risk assessments conflicted, and raised flooring created a trip hazard.

    “Some risk assessments contained conflicting information, meaning staff could not be sure of the safest way to keep people safe.” from the report

  • Medicines not always safe

    serious

    Some medicines were given at the wrong time, as-needed medicines were not always properly recorded, and staff had not always checked that crushed medicines were suitable to mix with food.

    “People were supported to receive their medicines in a way that was not always safe.” from the report

  • People's rights

    serious

    The home had not applied for DoLS for everyone who needed them. Staff did not always fully consider whether people with cognitive impairment could make their own decisions.

    “The registered manager had not fully understood the requirements of the MCA and had not applied for DoLS for everyone that needed them.” from the report

  • Weak oversight and records

    serious

    Audits did not consistently lead to action, and care records included unclear changes, duplicated assessments and notes that were not dated.

    “The providers audits had not been effective in driving improvements in the home.” from the report

  • Environment needs repair

    needs fixing

    Some wallpaper was damaged or peeling, and some flooring was raised. The registered manager said action had been taken after the inspection.

    “There were a number of areas where wallpaper was either damaged or peeling and therefore needs attention.” from the report

  • New staff safeguarding training delayed

    needs fixing

    New staff did not always receive safeguarding training promptly during induction.

    “However, this had not been prioritised for new staff, so there was a delay in them getting information on how to recognise concerns and raise them” from the report
Questions to ask them, based on this report
  1. 01What changes have been made to ensure every person's risks, pressure-area needs, nutrition risks and equipment are correctly recorded and reviewed?
  2. 02How are medicines now checked, including medicines given before food, as-needed medicines, and medicines crushed or mixed with food?
  3. 03Which people now have DoLS applications or other lawful arrangements in place, and how are best-interest decisions recorded?
  4. 04What actions were included in the provider's improvement plan, and how is progress being checked?
  5. 05How are people, relatives and staff now asked for their views about the care and improvements at the home?

This was a focused inspection of Safe and Well-led, widened to include Effective; Caring and Responsive were not inspected and their ratings were not given in this report. This explanation was written from the published report of 29 February 2024 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.

The story over the years

Every inspection of Bank House Residential Care Home

4 rated inspections over 7 years: the service has held its Requires improvement rating throughout.

  1. February 2024Requires improvementcurrent ratingdown from Good
    Safe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Bank House Residential Care Home →

  2. June 2018Goodup from Requires improvement
    Safe: GoodEffective: GoodWell-led: Good

    We are reading this report · the original is on cqc.org.uk

  3. August 2017Requires improvementstayed Requires improvement
    Safe: Requires improvement

    Read this report on cqc.org.uk

  4. March 2017Requires improvement
    Safe: Requires improvementEffective: GoodCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement

    Read this report on cqc.org.uk

  5. April 2016

    Registered with the Care Quality Commission on 19 April 2016.

Ratings and report dates from the Care Quality Commission. A service can also be visited without a new rating being published, so the timeline shows published inspections, not every contact the CQC has had with the service.

Another option

Or stay at home with a private carer

Many people who look at care homes end up staying at home with a carer who comes in for a few hours a day, or lives in. PrimeCarers introduces you to self-employed carers you choose yourself: interviewed, ID and DBS checked, from about £20 an hour or £1,120 a week live-in.

About live-in careHow PrimeCarers works
Nearby

Other care homes near Spalding

All in Lincolnshire

18 Water Gate

Spalding, PE11 · 3.9 km
Good
Residential
Rated 11 months agocare home

Stonehaven

Spalding, PE11 · 4.3 km
Outstanding
ResidentialDementia
Rated 6 years agocare home

Brun Lea Care

Spalding, PE11 · 5.4 km
Good
ResidentialDementia
Rated 7 years agocare home