About the service:

Bishops Croft provides residential care for up to eight people with Prader-Willi Syndrome (PWS). The main house provides accommodation for up to seven people and a single unit annexe is situated next to the main house. At the time of inspection there were four people living within the main house.

The service worked in line with the principles and values that underpin Registering the Right Support and other best practice guidance. The operations director told us the service was being reviewed along with other services within the organisation and this would take account of all design recommendations made within Registering the Right Support.

People’s experience of using this service:

•Since the previous inspection, improvements had been implemented. Risks to people’s safety were assessed and responded to. Staffing arrangements were suitable and medicines were safely managed. People’s capacity was assessed when decisions were made including those around people’s health. Record keeping and quality monitoring systems had improved.

•However, some records needed further improvement to ensure all information was used to improve quality and practice. We also found communication between the organisation and people’s representatives was not always effective. These areas needed improvement.

•The outcomes for people living at Bishops Croft were positive with person centred care provided by kind and supportive staff. Staff were committed to ensuring people had a full and active life that they enjoyed. People told us they had the opportunity to do lots of activity that they enjoyed. One person told us and showed us pictures of a celebrity that they had recently met during filming of a TV show.

•Staff knew how to keep people safe. They responded to any risks and took measures to reduce these. Staff had a good understanding of how to identify and respond to any suspicion or allegation of abuse.

•Staff supported people in the least restrictive way possible. Staff had attended Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training.

•Staff had a good understanding of the care and support needs of people and had developed positive relationships with them. People were supported to ensure their health needs were responded to and health needs were reviewed on a regular basis. People had their privacy and dignity protected.

•People's needs were effectively met because staff had the training and skills they needed to do so. Specialist training was provided to ensure people's needs could be met and refresher courses were booked when due. This included in depth training on PWS, which is a genetic disorder where people are constantly hungry.

•Staff attended regular supervision meetings and told us they were well supported. There were listened to and could influence how the service was run.

•The registered manager led by example and had an established a supportive environment for staff and people. She interacted positively with everyone at the service and ensured that a good relationship was maintained with all professionals. Staff felt appreciated and well supported. Complaints were recorded and responded to in an open way. Accidents and incidents were responded to appropriately.

Rating at last inspection:

Requires Improvement. The last inspection report was published on 04 October 2018. There were breaches and two warning notices served.

Why we inspected:

•At our last inspection of the service in June 2018 we found breaches in Regulation 12 in relation to safety, Regulation 18 regarding staffing arrangements, and Regulation 17 in relation to good governance. We issued warning notices in respect of Regulation 12 and 17 as these were repeated breaches.

•This was a planned comprehensive inspection that was scheduled to take place in line with Care Quality Commission (CQC) scheduling guidelines for adult social care services.

•At this inspection we followed up on progress made. The Reg

Bishops Croft provides residential care for up to eight people with Prader-Willi Syndrome (PWS). At the time of inspection there were five people living there. The main house provides accommodation for up to seven people and a single unit annexe is situated next to the main house.

Bishops Croft 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.

There was a registered manager in post. 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.

This is the third time the home has been rated requires improvement. At a comprehensive inspection in February 2016 the overall rating for this service was Requires Improvement with four breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 identified. At an inspection in April 2017 significant improvements had been made but there was one breach in Regulation 12 and the overall rating remained requires improvement. We asked the provider to complete an action plan to show improvements they would make, what they would do, and by when, to improve the key question in safe to at least good. The provider sent us an action plan stating they would have addressed the breach by October 2017.

This unannounced inspection took place on 14 and 19 June 2018 to check the provider had made suitable improvements to ensure they had met regulatory requirements. We identified there was a continuing breach of Regulation 12 and further breaches in relation to Regulations 17 and 18. This was because we could not be sure people always received care that was safe, risks to people’s care were not always addressed, for example in relation to the application of prescribed creams. Record keeping was not always up to date or accurate and some of the governance systems were not always effective. We were not assured that staffing arrangements were sufficient to meet people’s needs at all times. We also made a recommendation to ensure people’s individual capacity to make decisions was decision specific.

People told us they were happy and we observed staff interactions were very positive. Some people needed regular emotional support and this was provided with patience and understanding and in a kind and caring manner. People told us they would talk to their keyworkers if they had any worries or concerns.

People had varied programmes of activities based on their individual needs and wishes. This varied from work placements to college courses and regular use of the gym for various activities of choice. People’s spiritual needs were met. People told us they had regular opportunities to meet with friends at clubs, to visit them and invite them to Bishops Croft. They were supported to maintain contact with their families.

People’s needs were effectively met because staff had the training and skills they needed to do so. Specialist training was provided to ensure people’s needs could be met and refresher courses were booked when due. Staff attended regular supervision meetings and told us they were well supported. There were regular staff meetings and staff felt they were updated about the home and could share their views. Staff supported people in the least restrictive way possible. Staff had attended Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) training.

Staff had a good understanding of the care and support needs of people and had developed positive relationships with them. People were supported to attend health appointments, such as the GP or dentist.

We found breaches of the Health an

Bishops Croft is a care home providing residential care for up to eight people with Prader-Willi Syndrome. This was an unannounced inspection which took place on 25 and 26 April 2017.

At a comprehensive inspection in February 2016 the overall rating for this service was Requires Improvement with four breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 identified. We asked the provider to make improvements to ensure care and treatment met people’s needs and reflected their preferences. Systems and processes needed to be improved to enable the provider to assess, monitor and improve quality of services and ensure that accurate, complete and contemporaneous records were in place for each person. The provider needed to ensure that a system was in place to review risks based on people’s individual needs and ensure staff were appropriately trained and supported to enable them to carry out their role safely. Improvements were needed in relation to consent and decisions around Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). The provider sent us an action plan stating they would have addressed these breaches of regulation by June 2016. At this inspection we found that although some improvements had taken place one new breach was identified. A recent change to the structure of the organisation meant that some new systems needed time to become fully embedded into practice.

Bishops Croft did not have a registered manager in place. An acting manager had been in day to day charge. Implemented changes needed clear provider oversight to ensure they were fully embedded into practice.

Individual risks to people were not always identified to ensure people remained safe at all times. This included risks identified in relation to how peoples care was managed. Staffing levels at night did not demonstrate how people would be safe in the event of an emergency evacuation.

A training programme was in place to support staff, although information was needed to show how staff who needed support to complete training had this provided. Inductions for new staff were in place. The supervision programme had fallen behind but staff felt that they were supported and able to speak to the acting manager if they had any concerns.

People felt involved in choices and day to day decisions, however, Deprivation of Liberty Safeguards (DoLS) systems needed to be further improved to ensure that this was consistently effective and corresponding information recorded in care files.

People had keys to their own rooms and their personal space was respected. Staff needed to be aware not to have discussions regarding peoples care and support needs which may be overheard to ensure their privacy and dignity was maintained.

Staff knew people well and displayed kindness and compassion when supporting them. People were encouraged and supported to remain as independent as possible. Activities were varied and a weekly programme was available for people. People told us they were able to do the things they enjoyed. Care documentation been updated to make it more person centred. However further improvements were needed to ensure all information was reviewed and updated.

Systems were in place to manage people’s medicines and people told us they received their medicines at the right time. People were supported to have access to other healthcare professionals and organisations if needed and staff assisted people in making and attending appointments.

People were involved with changes in the menu and meal choices. People told us they were happy with the standard of food provided. People’s weights and nutrition were monitored regularly to ensure dietary requirements were reviewed if required.

Staff were aware of how to recognise and report safeguarding concerns. And notifications had been completed to CQC and other outside organisations when needed.

Systems and equipment used within the home, including gas, electrical a

This inspection took place on 02 February 2016. This inspection was unannounced.

This location is registered to provide accommodation and personal care to a maximum of eight people with learning disabilities. Eight people lived at the service at the time of our inspection. People who lived at the service were adults with learning disabilities. We talked directly with people and used observations to better understand people's needs.

The home had a registered manager. 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.

The registered manager was absent from work at the time of our inspection since 04 January 2016. The service was managed by a deputy manager. A registered manager from another of the provider’s homes and a regional manager visited the service every week to provide support.

Staffing levels were not adequate to ensure people received appropriate support at all times to meet their individual needs.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Not all staff had received training in the Mental Capacity Act (2005) and how to implement this in practice. DoLS applications were not up-to-date in all cases to ensure people were lawfully deprived of their liberty.

There were audit processes in place to monitor the quality of the service and promote continuous service improvements. However, audits were not sufficiently robust. Shortfalls we found had not been identified as part of the provider’s audit process. There was no service improvement plan in place to determine how the service would continuously develop and improve.

Each person’s needs and personal preferences had been assessed. However people’s care plans had not been regularly reviewed to ensure they were up-to-date and met people’s preferences and needs. People’s care plans were detailed, however the regional manager acknowledged information was generic in some care plans. They were working to make improvements to ensure people’s care plans were individualised to meet their specific needs.

People did not always receive person-centred care. Staff did not consistently responded to people’s individual needs and support people to meet their individual goals and aspirations. Where people had identified goals to achieve these were not consistently monitored and outcomes were not routinely recorded as part of people’s care reviews.

The provider had obtained people’s feedback about the service. However they had not routinely evaluated the feedback and recorded their actions in response to this feedback to improve the service

Staff received on-going training and supervision to monitor their performance and professional development. However not all staff found the training methods effectively met their learning needs.

We have made a recommendation about staff training needs and methods used to ensure staff have effective training to carry out their role.

Medicines were stored and administered safely and correctly. Staff were trained in the safe administration of medicines. However staff had not kept relevant records that were accurate in all cases.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns.

Risk assessments were centred on the needs of the individual. Each risk assessment included clear control measures to reduce identified risks and guidance for staff to follow to make sure people were protected from harm. Risk assessments took account of people’s right to make their own decisions.

Accidents and incidents were recorded and monitored to identify how the r

People told us that the care they received was good and that they liked living at Bishops Croft. They said that they enjoyed the activities provided. One person said, “I teach computers, spread sheets and how to do word documents, I like what I do.”

Another person said that they met with their keyworker regularly to discuss matters that were important to them. They said, “I really like my keyworker.”

We found that care plans clearly documented the needs of people and how they should be met. Staff ensured that consent was obtained prior to providing care and support. Specialist advice and support was obtained to meet people's individual needs. There were safe systems in place for the management of medication.

The home had a thorough recruitment procedure in place to ensure that they employed suitable staff to work in the home. People told us they were involved in staff interviews. One person said, “I don’t mind interviewing, it can be difficult but I know what I want to ask them.”

There were detailed systems to ensure that the quality of care provided was monitored and reviewed on a regular basis.

We spoke to people who used the service during our inspection visit. We also used a number of different methods such as observation of care and reviewing of records to help us understand the experiences of people who used the service. We spoke to people who have contact with the home on the 16 March 2013 and undertook the inspection visit on the 18 March 2013.

People we were able to speak with who lived in the service told us they liked living at Bishops Croft. We were told "Really good, sometimes I grumble but the staff listen to me," "I like it here, I have friends,” and "I know I'm safe, staff look after us very well."

During our inspection we found that people who used the service and/or their representatives were involved in decisions about their care and treatment. Care plans were personalised and documented the needs of people. Bishops Croft had a complaints policy and procedure in place. Evidence was seen that comments and complaints were listened to, and resolved in a timely and appropriate manner.

People liked their bedrooms and had been involved in decisions about redecoration. They were happy with the food in the home. Those spoken with also said that they enjoyed the wide range of activities on offer.