Bishops Gate is a care home providing residential care for up to eight adults with learning disabilities. In particular they provide residential care for people with Prader-Willi Syndrome (PWS). Whilst independent with many areas of their daily lives, people living at Bishops Gate require a high level of support to enable them to manage risk and remain safe.

This inspection took place on 11 August 2017 and was a full comprehensive inspection to check the provider met regulatory requirements. There were five people living at the home at the time of our inspection. One person was currently staying with family and another went to stay with family for a break during the inspection.

Bishops Gate was inspected in August 2016. Although no breaches were identified and it was rated as requires improvement as some recent improvements needed time to become embedded.

We asked the provider to continue to embed and sustain the improvements made. At this inspection we found this had taken place.

Bishops Gate had a manager registered with CQC. However they were no longer working at the service and had not been working in a registered manager capacity at Bishops Gate for some time. This meant that registration information did not reflect the current management structure at Bishops Gate. Since the inspection we have been informed that the process to de-register the registered manager and register the acting manager have been commenced. The acting manager worked full time at Bishops Gate and was supported by a senior carer/deputy manager who had just been appointed to this role.

An ‘in house’ and provider auditing and quality review system were completed, this included a number of regular audits and analysis of systems and processes. There were ongoing maintenance systems to ensure safety was maintained at Bishops Gate. Provider structure had been changed since the previous inspection and further improvements were planned to ensure a robust provider oversight was maintained.

Care documentation was reviewed to ensure it was relevant and person centred and people had been involved in the planning and review of their care. Risk assessments had been completed for identified risks and managed in a safe and consistent manner. These were varied and included environmental risks for people in relation to PWS. Risk assessments were individualised and person centred and had been reviewed and updated regularly, dependant on people’s health related conditions, behaviours and activities attended. Keyworker meetings took place to discuss changes in peoples care needs and to enable a review of documentation. Support plans had been reviewed and information had been discussed with people and their next of kin if appropriate. People had signed when they had read support plans and felt involved in how their care was provided. Staff were aware of confidentiality and documentation was kept securely.

There were systems in place to manage people’s medicines safely; this included a regular auditing of the medicines procedure People had chosen whether their medicines were stored in locked cupboards in their rooms or in the medicine room. Medicines were given in the privacy of people’s rooms or in the office as they chose.

Nutrition was managed effectively. Systems were in place to ensure people received appropriate nutrition to meet their individual needs. People had been involved in discussions at ‘Your Voice’ meetings regarding menus. Daily calorie intakes had been calculated for each person based on advice from health professionals and taking into consideration peoples specific health needs. Weights were monitored and changes made to nutritional plans if needed. Further changes to the menu were being introduced to facilitate healthier eating options.

Staff knew people’s needs and had a close bond with people, most of whom had lived at Bishops Gate for some time. People were involved in decisions and staff respected their personal space and privacy. Staff

Bishops Gate is a care home providing residential care for up to eight adults with learning disabilities. In particular they provide residential care for people with Prader-Willi Syndrome (PWS). Whilst independent with many areas of their daily lives, people living at Bishops Gate require a high level of support to enable them to manage risk and remain safe.

There were five people living at the home at the time of our inspection. One person was currently staying with family for two weeks and another went to stay with family for a holiday during the inspection.

Bishops Gate was inspected in December 2015. A number of breaches were identified and it was rated as inadequate. The Care Quality Commission (CQC) took enforcement action and the service was placed into special measures. CQC issued two Warning Notices after the inspection in respect of safe care and treatment and good governance. We also found further breaches in relation to the numbers and skills of staff to meet people’s needs and a lack of support systems in place for staff.

We asked the provider to make improvements to ensure peoples risks were identified and responded to. Improvements were needed to medicines, staffing levels, training and support for staff, nutrition, person centred care and documentation, consent, dignity, maintenance and equipment checks, assessing the quality of the care and support provided, auditing and quality assurance systems at the service. The provider sent us an action plan stating they would be addressed by July 2016.

This inspection took place on 15 and 16 August 2016 and was a full comprehensive inspection to check the provider had made suitable improvements to ensure they had met regulatory requirements. We found that appropriate actions had been taken and issues had been addressed and the service no longer required to be in special measures.

Bishops Gate did not have a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

An acting manager had been appointed and had worked at the service since the previous inspection. The acting manager told us they were in the process of registering with CQC and we saw evidence to confirm this. They were supported by a deputy manager to ensure a consistent management oversight at the home at all times.

Medicine procedures had been greatly improved. Daily checks had been introduced to ensure people received medicines safely. Further changes to the storage would be implemented once the refurbishment was completed. People were able to be involved in choosing where they received their medicines and were kept informed of any changes. Further changes to medicine procedures and how they are stored and given were in progress as refurbishment to the building was not yet fully completed. These would be reviewed at the next inspection to allow the changes time to become fully implemented and embedded into practice.

Care provision and documentation had been reviewed with a new format for care planning in place. This was person centred and involved people and their Next of Kin (NoK) in the planning and review of their care. Risk assessments were completed for identified risks, this included fire risk assessments and night staffing levels to ensure peoples safety could be maintained at all times. Risk assessments were reviewed regularly and updated when changes occurred. Care documentation had been updated to ensure it was clear, relevant and person centred to reflect peoples differing support needs.

A varied activity programme was available for people. People had access to activities they enjoyed and were supported by staff to attend. People were encouraged and supported to remain as in

People told us that they were happy living at Bishops Gate. One person told us, the decision to move to Bishops Gate had been the right decision. They said, “It was the best thing ever coming here.” Another person told us, “I’m happy here. The best this about here is that you get to make choices.”

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.

Staff received training to enable them to fulfil their individual roles and responsibilities. There were systems in place to ensure that anyone who wanted to make a complaint could do so.

We spoke with five of the seven people living in the home. Two people spoken with said that they had been unhappy in previous placements but that now they felt safe. One person said, “This is the best place I’ve ever lived and Mandy is the best manager”. Another person said, “I like the fact that it is a specialist home with rules and I know the boundaries, I need boundaries”.

Bishops Gate is a care home providing residential care for up to eight adults with learning disabilities. In particular they provide residential care for people with Prader-Willi Syndrome (PWS).

This comprehensive inspection was undertaken on 18 and 22 December 2015 and was unannounced.

The service had a registered manager in post, however, they had not worked at Bishops Gate for approximately two months, and told us they were now working solely at a ‘sister’ home for which they were dual registered. ‘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. An acting manager had been appointed, with a view that they would register as manager once their induction was completed. Although the acting manager had been employed by the organisation for six weeks they had not been working full time at the location as they had been attending training. In the absence of the registered and the acting manager working at Bishops Gate, standards of care and documentation had not been maintained.

Medicine procedures were inadequate and we found a number of issues which meant that people’s medicines had not been given to them as prescribed. Staff were making changes to doses of medicine based on verbal information from staff member to staff member, with no documented evidence in place to support the changes made.

Care plans and risk assessments had not been reviewed in all care files within designated timescales. There was a lack of clear and up to date guidance in place to support staff. Risks to people had not been well managed and supporting documentation completed when required. Protocols were not in place to give clear guidance to staff around one to one care provision and documentation for people was not person centred. Staffing levels at night had not been reviewed to address identified risks for people and it was unclear how these would be maintained at all times.

Maintenance checks to the building and equipment had not been completed appropriately.

Recruitment processes needed to be improved. Information regarding support needs for staff identified during interview had not been risk assessed and adequate support needs provided. Staff supervision had not taken place in accordance with the organisations policy and staff had not been adequately supported after incidents.

Good governance had not been maintained. Systems and processes were not carried out effectively. Provider and management audits had identified a number of issues. These had not been responded to in a timely manner to continually improve care delivery and ensure quality and safety within the service.

Staff were aware how to recognise and report safeguarding concerns. Staff had a good working knowledge of MCA and DoLS, with information available for people living at Bishops Gate in an easy read format.

Staff endeavoured to provide a safe and supportive environment for people, however this was not supported by adequate information, guidance, experience and a clear management system to ensure consistency at all times.

A varied activity programme was available for people. This included work placements, trips out and activities provided on site. People were also supported to participate in day to day household tasks to teach and support daily life skills.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.