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CQC report explained · a nursing home, run by Glenholme Senior Living (Bispham Gardens)

Bispham Gardens

Ryscar Way, Bispham, Blackpool, FY2 0FN

Requires improvementpublished 20 December 2023, 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 linked to pressure care, wounds and equipment were not always assessed or managed safely. Medicines, infection control, recruitment and safeguarding systems were otherwise described positively, although some medicines records needed improvement.
Effective?
Good
This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
Caring?
Good
This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
Responsive?
Good
This question was not inspected during this focused visit. Its rating was carried over from the previous inspection.
Well-led?
Requires improvement
Audits and checking systems had failed to identify or address important shortfalls. Staff were also unclear about who was responsible for some safety checks, although people, relatives and staff said the manager was approachable and listened.
The latest report, explained

What inspectors found, December 2023

Rated Requires Improvement; inspectors found unsafe risk management and weak checking systems, although staff were caring and infection control was good.

This was an unannounced focused inspection on 10 and 18 October 2023. Inspectors looked only at Safe and Well-led. They spoke with people, relatives and staff, observed care, checked medicines and records, and reviewed audits and training.

Inspectors found that risks were not always managed safely. Pressure care assessments and repositioning records were incomplete, some wound care could not be shown to have been followed, and some equipment was not fit for purpose or had not been fully risk assessed. These problems led to a breach of Regulation 12.

There were also positive findings. Medicines were generally managed safely, the home was clean, infection control was good, and people and relatives spoke positively about staff and management. The home was rated Requires Improvement for Safe and Well-led, and the overall rating changed from Good at the previous inspection.

What inspectors praised

  • Medicines were generally safe

    Staff who administered medicines had training and competency checks. Inspectors observed medicines being given in line with best practice and found they were stored safely.

    “Medicines were managed safely and properly.” from the report

  • Good infection control

    Inspectors were assured about infection prevention, the use of protective equipment and the arrangements for visitors and infection outbreaks.

    “We were assured that the provider was using PPE effectively and safely.” from the report

  • People felt safe and listened to

    People and relatives gave positive feedback about safety, staff and the manager. The manager used meetings, surveys and staff feedback to hear people's views and act on them.

    “The provider engaged with people who used the service and others acting on their behalf.” from the report

  • Learning from incidents

    Accidents and incidents were reviewed for patterns and lessons were shared with staff to reduce the chance of similar events happening again.

    “Staff recorded accidents and incidents, which the manager reviewed on a regular basis to identify any trends, themes and areas for improvement.” from the report
What inspectors were concerned about

  • Pressure care and risk records

    serious

    One person's pressure care risks were not assessed until six weeks after admission. Records also had significant gaps in repositioning, and staff could not show that another person's wound care plan had been followed.

    “The management of risk was not always safe and some records related to people's care were not accurate and up to date.” from the report

  • Equipment checks

    serious

    Some mattresses were not fit for purpose and some equipment had not been fully risk assessed. Staff did not always follow plans for safe equipment use.

    “We found a number of mattresses were not fit for purpose, despite being checked, and equipment that was in use without having been risk assessed thoroughly.” from the report

  • Audits did not lead to action

    serious

    The home's own audits failed to identify some important problems, or did not ensure that known medicines-record issues were fixed. This was part of the breach relating to safe care and treatment.

    “These had not all been operated effectively to identify and address the shortfalls we found during our inspection.” from the report

  • Unclear staff responsibilities

    needs fixing

    Staff gave different answers about who was responsible for checking mattresses and repositioning records. Management said staff responsibilities were refreshed after the inspection.

    “We found confusion among staff about their responsibilities.” from the report

  • Some medicines records incomplete

    needs fixing

    Guidance for medicines given when needed and photographs in some medicines records needed improvement. These issues had been identified a month earlier but had not yet been fixed at the inspection.

    “These shortfalls had been identified 1 month before but had still not been addressed at the time of our inspection.” from the report
Questions to ask them, based on this report
  1. 01What has changed since the inspection to make sure pressure care risks are assessed promptly?
  2. 02How do you check that repositioning and wound care are carried out and recorded as planned?
  3. 03Which mattresses and other equipment have now been checked, and how are staff told to use them safely?
  4. 04Who is responsible for checking mattresses and repositioning records on each shift?
  5. 05Have the medicines guidance and missing photographs identified in the audit now been corrected?

This was a focused inspection of Safe and Well-led only; the Effective, Caring and Responsive ratings carried over from the previous inspection. This explanation was written from the published report of 20 December 2023 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 Bispham Gardens

2 rated inspections over 4 years: the service has slipped, from Good to Requires improvement.

  1. December 2023Requires improvementcurrent rating
    Safe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement

    Read what inspectors found at Bispham Gardens →

  2. November 2020Inspected but not rated
    Safe: Inspected but not rated
  3. April 2020Good
    Safe: GoodWell-led: Good
  4. August 2023

    Registered with the Care Quality Commission on 16 August 2023.

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.

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