Bankfield House Care Home

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

The rating for this key question is requires improvement. We identified a breach of regulations in relation to safe care and treatment and a breach of regulations in relation to safeguarding people from abuse. We identified concerns with the management of medicines and the management of people’s individual risks, including safe moving and handling of people and health and safety risks to people. We were not assured that safeguarding concerns and events were always fully reported and investigated. People told us they felt safe and there was enough staff around during the day; however, some people told us they had to wait too long for assistance. Staff demonstrated their knowledge about safeguarding and how to raise any concerns.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People told us they felt safe living at Bankfield House and people did not raise any serious concerns about safety at the home. One person told us, “I feel safe because I know they [staff] will help me if I need it.” We found people did not always have their risks addressed, effectively reviewed and actioned when an incident had occurred; this meant people were not always protected from further incidents.

The home manager told us they analyse accidents and incidents and reviewed CCTV footage. However, we did not find any evidence of analysis or thorough investigations when incidents had occurred. The area manager acknowledged this was an area identified for improvement and told us they had plans to introduce a system to analyse accidents and incidents.

The provider did not have robust systems in place to ensure lessons were learned and action taken in response to incidents. There were no formal processes in place to identify any learning from events and therefore any mitigation for future incidents was not consistently shared with staff. We were not assured the provider undertook necessary investigations and actions to protect people and minimise further risks.

People mostly told us they felt safe at the home and did not raise any concerns with us about referrals to healthcare professionals. However, we found people's experience was that they did not always receive timely healthcare input when needed.

The home manager told us they would speak to the home’s visiting GP when someone needed a referral to a healthcare professional. They told us people were weighed monthly and if someone was losing weight, they would tell the GP during their weekly ward round and a referral would be made by the GP. However, we found this did not always happen as we identified people who had lost weight and no action had been taken.

We received mixed feedback from partners. We were told concerns had been raised by healthcare professionals prior to the new management team’s arrival; however, they now felt improvements were being made.

There was no set procedure or pathway in place for staff to identify a concern about a person and then escalate the concern to the management team. The home manager told us they became aware of a concern about a person if it was discussed at handover meetings between staff teams.

People told us they felt safe. One person told us, “I do feel safe here, some of the staff are very friendly.” However, people also told us they did not always receive timely assistance when needed. We found that people were not always safeguarded from harm as appropriate action had not always been taken when incidents occurred.

Not all staff had completed training on safeguarding. However, staff we spoke with were aware of how to report incidents and felt confident to report concerns and how to whistle blow. One staff member told us, “, if I saw anything wrong, I would go straight to report it.” The home manager told us they would report incidents to the local authority and completed weekly returns to inform them of any incidents at the home. We reviewed the actions of a recent safeguarding investigation by the local authority and found the actions reported to be in place to protect a person were not always being carried out in practice. This meant the person could still be at risk of repeat incidents.

We observed staff mostly assisting people at the home in a safe way. However, we also observed instances where people were not assisted to move safely. For example, we observed one person was transported through the home in a wheelchair without the use of footplates or a safety belt and was left unattended without the brakes applied. We also observed a person being hoisted from their wheelchair without the brakes applied. These actions placed people at the risk of injury from unsafe use of moving and handling equipment.

Systems to ensure safeguarding concerns were appropriately identified and investigated were not robust. During this inspection we found a breach of regulations relating to the safeguarding of people from abuse. We were not assured people were always protected from the risk of abuse and we were not assured all incidents were being reported as required. We asked about the submission of statutory notifications to advise CQC of incidents and the home manager told us the local authority safeguarding team had informed them they should not notify CQC of a safeguarding incident; however, they did not produce any evidence of this directive. We raised a safeguarding referral with the local authority due to our concerns relating to the lack of evidence of an appropriate investigation relating to one incident at the home.

People were not always supported appropriately and safely with their individual conditions and did not always receive their care and support in a safe way. Care plans did not demonstrate that people and their families were always involved in managing risks as this was not reflected in documentation.

The home manager told us they put in place an emergency care plan within 24 hours when a person first came to live at Bankfield House. The home manager told us where someone did not have the capacity to be involved in managing their own risks, they would make their families aware of those risks. We did not see any evidence of contribution or involvement in risk assessments from people themselves or those with legal powers to represent them.

The management of individual risks was not always safe. Information in care plans for staff to follow was not always clear, up to date or accurate. We found some people required to be assisted to reposition to reduce the risk of damage to their skin; however, this was not fully followed. We also found information was not clear for some people relating to their diet and hydration needs. Our observations also identified concerns with the safe moving and handling of people by staff at the home.

We found concerns with people’s individual risk management, for example, monitoring charts and daily notes were not comprehensively completed. People’s care plans and risk assessments contained conflicting information and were not always accurate. One person had developed a pressure wound and there was no body map or risk management plan found in care documentation and their Waterlow assessment for skin integrity had not been reviewed for over 3 months. We found information for staff about people’s diet and fluid requirements was conflicting and unclear for staff to follow. We found one person had been assessed by a speech and language therapist as requiring a level 4 pureed diet and level 3 thickened fluids; however, their care plan front sheet stated they needed 4 scoops of thickener in their drink and did not mention their dietary needs. This was a breach of regulation relating to safe care and treatment and the management of individual risks.

Some areas of the home had been renovated and the home’s handy man was redecorating communal areas at the time of our inspection. There were still areas of the home that needed refurbishment and the provider told us they had a plan in place to update the whole of the home over a period of time. We found some people’s bedrooms were in good condition and we found some bedrooms needed improvement. One person’s bedroom had a strong malodour and we requested this was addressed; this had been resolved on our next visit. On the second day of our site visits, we identified the call bell system was not working correctly and was displaying incorrect information. This had not been noticed by staff prior to us finding this concern. We asked the handyman to check the system and they told us they had found two call bells did not have functioning batteries.

The home manager told us they arrived for work early each day and went around the building to check people were well and had call bells. They told us they checked the home was clean and bins had been emptied. They said they wanted people and staff to feel their presence at the home. During our site visits we found people often did not have call bells within their reach or did not have any access to a call bell as some sockets were empty. We fed detailed information back to the home manager and provider and asked them to rectify our concerns.

People had been placed at the risk of harm as we found several safety concerns relating to the health and safety of the environment and equipment. People’s wardrobes were not always secured to the wall causing a risk of injury. Radiators were not safely covered and some hot pipework was exposed and this was a burn risk to people. Emergency call cords in all bathrooms and toilets were tied up and did not conform to published standards relating to height settings. We found two people had side bed wedges that had been incorrectly placed underneath their mattresses meaning they were in bed in an unsafe position. On the first day of inspection, we found the bath lift did not have a safety belt and one person’s airflow mattress was set significantly higher than their actual weight. We reported this to the management team; however, when we returned for the second day 8 days later, we found these concerns had not been rectified and this meant people continued to be placed at the risk of harm from unsafe equipment.

We found a breach of regulation relating to safe care and treatment relating to the safety of premises and equipment. Processes were not always robust in identifying and actioning areas of potential risks to people at the home. We were not assured that safety checks of the building/environment had been fully and regularly completed as these were not produced during the inspection. These included fire and water checks and checks of equipment.

We received mixed feedback from people about the availability of staff to meet their needs. Some people were positive about staff presence; however, several people told us they had to wait too long for assistance once they had used their call bell. One person told us staff did not always attend when they had used their call bell and one person told us they sometimes had accidents when staff did not attend when needed. People gave us examples of how long they had to wait to be attended to by staff. One person told us they regularly had to wait over one hour for assistance. One person commented, “I would like them to see to me quicker when I need them.” Another person told us, “At night, I don’t’ know what they [staff] are doing; they have not turned up when I use the bell.”

The home manager told us new staff underwent a programme of induction and all staff received ongoing support through supervision and appraisal. Staff confirmed they received support from the home manager. We received mixed feedback from staff around the staffing levels. One staff member told us, “Some days it’s alright, some days it’s not…They struggle more on nights.” The home manager told us they use a dependency tool to determine how many staff were needed on each shift. They told us there were 3 care staff on duty at night; however, they also told us that 10 out of 26 people living at the home required the assistance of 2 staff members. This meant there was a risk that there would not be enough staff to assist people in a timely manner during the night shift and reflected what people told us.

Our observations of staff availability demonstrated people did not always receive timely assistance and we observed multiple instances where people were not helped when necessary. We found people did not always receive the help they needed at mealtimes and this led to a poor experience for them and placed them at risk of harm. On day one of the inspection, we found an additional care staff member had been brought in to be on shift from the provider’s other care home in Wales and had not worked at Bankfield House before. There was no activity co-ordinator at the home and there were not enough staff to plan and provide meaningful activities for people. We observed staff were doing their best to provide activities; however, we noted this was ad hoc and an additional task to care staff duties.

We reviewed the recruitment process at the home. We initially found the process was not robust to ensure only staff with good character were employed. We found several important gaps in the recruitment records of staff. We were later given written assurances that all pre-employment checks had been completed and the provider was satisfied that staff had been recruited safely. However, these gaps had only been identified during our inspection and had not been in place prior to our site visit.

People told us they thought the home was clean. One person told us, “My room is very warm and clean.” Another person commented, “My room is very clean they [staff] are always giving it a hoover.”

The home manager told us they ensured staff completed training in the donning and doffing of personal protective equipment (PPE). They told us staff were also reminded each day in handover meetings regarding the safe use of PPE. We advised the management team of the potential risks associated with accessibility of disposable gloves.

The home mostly looked clean and tidy. However, there were some areas of the home that required refurbishment, for example, some flooring needed replacement and some corridor and bedroom walls required repair and redecoration.

The provider had carried out their own infection control audit in August 2024 and identified only 3 areas of non-compliance. However, an IPC audit conducted by the local authority IPC team in September 2024 assessed Bankfield House as only being 72% compliant with IPC requirements. We found that not all staff had completed infection prevention and control (IPC) training.

We witnessed staff safely add thickening agents to drinks for people with swallowing difficulties. However, at the time of assessment, records were inconsistent and incomplete. Therefore, we could not be assured that people were always safe from the risk of choking. We saw that high-risk medicines such as anticoagulants were managed safely. One person was prescribed a different dose of medicine each day and this was clearly recorded. When people had their medicines covertly, hidden in food or drink, information to support staff to safely give medicines this way was not always available and the service’s covert medicines policy and national standards were not adhered to. Therefore, there was a risk that people were not given their medicines safely. Whilst staff demonstrated good knowledge of people’s medicines needs, care plans did not always have up to date, personalised information about how to support people with their medicines. Person-centred information was not always in place to support staff to safely give ‘when required' medicines to people. There was a risk that people might not have got their medicines when they needed them.

Staff had dedicated time to manage medicines processes such as ordering and receiving. Managers told us that staff had completed medicines training and had been assessed to ensure that they gave medicines safely. We were shown evidence of training records to confirm this. Medicine audits were carried out regularly. However, they were not always effective in identifying medicines related issues occurring in the service.

Medicines were ordered in a timely way and checked when they arrived at the service. There was an effective process for managing stocks levels. Overall, medicines were stored safely and securely. However, creams were kept in people’s rooms without appropriate storage risk assessments being completed. There was a risk that they could be inappropriately accessed. We found one person’s cream chart contained incorrect information. People’s allergies were not always accurately recorded. Handwritten entries on medicines records had not been checked by 2 members of staff as per the medicines policy and were not always accurate. There was a risk that medicines could have been given incorrectly.