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

This comprehensive inspection was undertaken on 7 March 2017 and was unannounced.

Since the last inspection the registered manager had left and the home did not have a registered manager in post. Currently a manager registered at a sister service was in charge of the home supported by senior staff within the organisation. Recruitment was in progress for a new manager to work at Bishops Way. A registered manager is a person who has registered with the 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.’

At a comprehensive inspection in January 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; that care was provided in a safe way for people and risk had been assessed. Systems and processes needed to be improved to enable the provider to assess, monitor and improve quality and safety of services and ensure that accurate, complete and contemporaneous records were in place for each person. The provider needed to ensure that a system as 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.

The provider sent us an action plan stating they would have addressed these breaches of regulation by April 2016. At this inspection we found that improvements had been made and the provider was now meeting all regulations.

Although there was currently no registered manager at Bishops Way the acting manager had ensured there was clear and consistent leadership at the service.

All areas of documentation had been reviewed and new systems implemented if needed. Care documentation was person centred and included relevant information about people and their care needs. Systems and processes were in place to assess and continually improve the quality of care. Care planning was now done by people’s keyworkers and the individual was involved and people signed the documentation to show they agreed to the information and any changes or updates. Care planning was written in association with risk assessments for individual or environmental risks identified. This included risks in association with specific health needs and nutrition.

Medicine procedures had been improved this included daily and monthly checks. Medicines were now stored in locked cupboards in people’s bedrooms. People told us they liked this way of having their medicines as they were able to talk to staff about them and were involved in the procedure throughout. Staff felt that this had improved communication and meant that people could be involved as much as was possible.

Plans were in place for an overall refurbishment of the home. Maintenance issues were reported and minor concerns had been addressed. Regular checks had taken place to ensure that water systems, electrical appliance and gas systems were safe and equipment servicing completed annually as stated. A fire risk assessment was in place and personal emergency evacuation plans (PEEP’s) had been completed for people if an emergency evacuation was required.

Staff had a good understanding of safeguarding and the acting manager was aware of their responsibility for reporting concerns. There was a clear system in place in the event of accidents and incidents. Incident forms were completed and any information shared with the provider and reported to CQC or local authorities as requir

This inspection took place on 13 January 2016. This inspection was unannounced.

This location is registered to provide accommodation and personal care to a maximum of four people with learning disabilities. Four 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 did not have 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 manager of the service had been in post since September 2015. They were manager for two services within the provider group. They spent their time working between the two services. They told us they were in the process of applying to become a registered manager of this service.

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.

Some records to include a business continuity plan and fire procedures needed to be updated. These procedures did not robustly support continuity of the service in adverse conditions or support people to safely evacuate the premises in the event of a fire.

Staff received on-going training to monitor their performance and professional development. However not all staff had attended necessary training to safely meet the requirements for their role. Measures had not been implemented to address this shortfall.

Staff had received regular supervision to monitor their performance and development needs. However supervision records did not provide detail of staff performance and development needs and evidence of progress in meeting these needs.

Staff did not consistently responded to people’s individual needs and support people to meet their individual goals and aspirations. 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 develop the service and meet people's individual needs.

There were audit processes in place to monitor the quality of the service. However, audits were not sufficiently robust. Shortfalls we found on the day of the inspection for medicines and maintenance issues 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.

People’s care plans were reviewed with their participation and relatives were invited to attend the care reviews and contribute. However not all care plans were up-to-date to reflect people's most current care and support needs.

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 risks of reoccurrence could be reduced.

There were sufficient staff on duty to meet people’s needs.

There were safe recruitment procedures in place which included the checking of references.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The manager understood when an application should be made and how to assess whether a

A single inspector carried out this inspection. The focus of the inspection was to answer the key question; is the service safe.

Below is a summary of what we found. This summary describes what people and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

Most of the staff team had attended training on report writing and further training was also being arranged. Records of accidents and incidents were detailed. There were systems that ensured that the management team monitored the quality of record keeping ensuring that it was clear and accurately described events that occurred.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. There was only one person at home on the day of inspection. This summary describes what they and the staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

There were enough staff on duty to meet the needs of the people living at the home and a member of the management team was available on call in case of emergencies.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw that management had completed recent training on the subject and DoLS applications had been made when needed.

Incident records did not always contain detailed and accurate information of events that occurred in the home. This meant that the provider was not always able to demonstrate that people had been supported appropriately and in line with their assessed needs.

Is the service effective?

Staff spoken with had a good understanding of people’s support needs. One person told us that they were happy with the care they received and felt their needs had been met. They said there were enough activities and although they had a set activities through the day that they took part in, they could opt out at times if they chose to. We saw that when people needed specialist advice and support, arrangements were made for this to happen.

Is the service caring?

People were treated with respect and staff were courteous. We saw that staff showed patience and understanding when supporting people. One person told us, “I like living here and I get along with everyone.” We asked if staff discussed their care plan with them and they said, “Yes, X tells me what is in it and I sign it if I am happy to.”

Is the service responsive?

We saw that people’s needs were regularly reviewed. Records confirmed that people’s preferences, interests and diverse needs had been recorded. We saw that people had been supported to maintain relationships with friends and relatives. One person who was away for a few days contacted the home during the inspection to speak with a person and with staff.

Is the service well led?

We saw that the organisation had developed a range of measures to monitor the quality of the service provided at Bishops Way. One person told us that they had regular residents’ meetings. They said, “We meet to talk about menus and if we want to make any changes.”

People spoken with said that they were treated well. They met regularly with their key workers to talk about their needs and to update their care plans. They said they had lots of activities. One person said “I like going to church” and that they enjoyed all the activities that they participated in.

People spoken with said that the food was good. They said that there were lots of activities and that they were supported to use the community on a regular basis.

We carried out our inspection on 10 May 2013 and returned to the home on 14 May 2013 to look at one particular aspect of our inspection.

We spoke with three of the four people living in the home. One person said, “I like living here.” Another said, “We chose the furniture for the lounge.” One person said that they liked their day time activities and they were keen to show the arts and crafts work that they had produced on the morning of inspection. People said that they discussed issues like menus and holidays at their residents meetings and they were able to raise their individual views.

We were told that people contributed to the organisation’s website by writing about various activities that they had participated in. They also enjoyed putting photographs of their activities on this site.

Care plans included detailed information about the needs and abilities of people. There was evidence that people were involved in making decisions about their care.

The home was well maintained and was clean. Staff received training and support that enabled them to meet the needs of people.

The provider had systems in place to continually monitor and improve the service.