The inspection took place on 22 and 28 January 2019. The first day of the inspection was unannounced.

We last inspected the service in February 2018 and found the provider had breached two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. These related to the systems and processes used to manage medicines safely and record keeping. We asked the provider to complete an action plan to show what they would do to improve the service.

Bishopsgate Lodge Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates 47 people across three floors. At the time of the inspection 42 people were being supported in the home, 15 requiring nursing care and some were living with dementia.

The service had 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.’

At this inspection we found the provider had taken action to improve.

The provider had introduced additional documentation to support the administration of medicines. Medicines were managed by staff trained in the administration of medicines. Observations demonstrated people received their medicines safely. The provider had employed a clinical lead to provide additional support to nursing staff.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Risks to people were assessed and plans put in place to mitigate against them. Risk assessments were reviewed regularly or when there was any change in the person’s needs. Risk assessments for the environment such as slips, trips and falls were in place and reviewed regularly.

Recruitment processes were in place with all necessary checks completed before staff commenced employment. Nurses had their professional identification numbers (PIN) checked on a regular basis.

The provider used a dependency tool to ensure staffing levels met the needs of the people living in Bishopsgate Lodge. Staffing rotas were completed in line with the dependency tool.

The provider had a business continuity plan in place for staff guidance in case of an emergency. People had Personal Emergency Evacuation Plans (PEEPS) in place which were updated regularly.

Staff were aware of safeguarding processes and knew how to raise concerns. Where lessons could be learnt from safeguarding concerns, these were used to improve the service. Accidents and incidents were recorded and monitored as part of the provider’s quality assurance system.

The provider ensured appropriate health and safety checks were completed. We found up to date certificates were in place which reflected gas safety checks and mobility equipment checks.

We found staff received regular supervision and an annual appraisal. Opportunities were available for staff to discuss performance and development. Staff training which the provider had deemed mandatory was up to date.

People’s nutritional needs were assessed and we saw people enjoying a varied diet, with choices offered and alternatives available. People were supported with eating and drinking in a safe, dignified and respectful manner. People had access to healthcare professionals when necessary and were supported with health and well-being appointments.

The provider had systems and processes in place to ensure the principles of the Mental Capacity Act 2005 (MCA) were being met.

People and relatives

This inspection took place on 9 and 15 March 2018 and was unannounced. This meant the staff and provider did not know we would be visiting.

Bishopsgate Lodge Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Bishopsgate Lodge Care Home accommodates 51 people in a purpose built building, across three floors. Some of the people living there were receiving nursing care and some people had a dementia type illness. On the day of our inspection there were 44 people using the service.

The service had a registered manager in place. A registered manager is a person who has registered with CQC to manage the service. Like 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.

We last inspected the service in December 2015 and rated the service as ‘Good.’ At this inspection, we identified issues with the management of medicines. One person used an inhaler however their risk assessment was not up to date. Some people were prescribed PRN (as required medicines). However, for some people PRN protocols were not in place or did not contain sufficient information. One person’s hand written medicines administration record (MAR) had not been countersigned by a second member of staff to confirm that the record was accurate. For one person whose medicines had been changed, it was not clear who had authorised the discontinuation.

For a medicine that staff administered as a patch, a system was in place for recording the site of application and the days when the patches were renewed or replaced. However, staff had not fully completed this for one person. Some people received support with medicinal creams. We saw that a body map was in place for one person to show where the cream should be applied however there was no record to confirm when the cream had been applied. For three people a medicinal cream was listed on their MAR however there was no body map or topical MAR to show where the cream should be applied. The service conducted a number of medicines audits however these were not robust and had not identified the issues we found.

We identified issues with record keeping that had not been addressed following internal audits of the service. For example, one person’s support plan indicated that they had “fluctuating capacity”. The deputy manager told us the person did not have fluctuating capacity and were able to make decisions independently. In all the care records we viewed, consent to care on individual support plans was not signed by the person if they were able or by a legally authorised representative. In two people’s records, we saw no written consent for photographs or for the use of bedrails. We also found food and fluid charts had been inconsistently recorded.

Care records were regularly audited however most of the records we viewed had identified actions that had not been signed or dated to say the action had been completed. For example, a care records audit for one person, dated 9 January 2018 included a number of actions including re-writing all the support plans. We checked the person’s care records and saw the communication support plan had been re-written but none of the other support plans had been re-written since January or February 2017. Therefore, actions from the audit had not been completed.

Accidents and incidents were appropriately recorded and risk assessments were in place. The registered manager understood their responsibilities with regard to safeguarding and staff had been trained in safeguarding vulnerable adults.

The home was clean, spacious and suitable for the people who used the service, and appropriate health and sa

All of the people expressed satisfaction with the care and service they received. One person told us, “If I need anything I will generally ask the staff. I can always ask them for things”.

We were able to observe the experiences of people who used the service. We saw that staff treated people with dignity and respect. We saw that they were attentive and demonstrated knowledge and understanding of people’s needs. Staff encouraged and supported people to make choices and be independent. We observed that people were seen to respond positively to the staff throughout.

People we spoke with told us they were involved in decisions about their care. Comments from people included “They are champion here, the staff are really good, and they listen to me.”

People who used the service explained how their care and welfare needs were met. One person said “I have been ill during the night, I can call the staff and they will come”.

During the inspection we spoke to people using the service and they told us they could speak to staff about any concerns they may have. One person told us “They have been so good to me, really very nice, I wouldn’t change it”.

We were able to speak with all the staff on duty at the home. All of the staff told us they felt well supported by the manager and supervisors. They told us they received regular training and they were encouraged to ask for support when needed. On the day of the visit an occupational therapist was visiting and she told us “The staff are very helpful and knowledgeable. I know I can speak with the manager at anytime”.

We found that there was an effective system to regularly assess the quality of service that people received. We found that the views and opinions of people using the service and their carers, family and relatives were also regularly recorded.

We spoke with several people who used the service. Everyone spoke positively about the care they received.

People we spoke with told us they were involved in decisions about their care. On the day of our visit a dentist was visiting the home. People living in the home described how the staff had asked them if they wanted to see the dentist. Comments from people included “I said to them I don’t want to see the dentist. The staff respected my decision.”

We observed staff providing care and support to people throughout the inspection. There was a calm, friendly atmosphere around the home and people were seen to respond positively to the staff throughout. People were well presented and appeared cared for.

People who used the service explained to us how their care and welfare needs were met. One person said “The staff get the doctor in if I’m feeling bad.” Another person told us “I felt dizzy one night and couldn’t reach the buzzer so I shouted. The staff came straight away.”

People’s nutritional needs were met. Comments from people included “The food is beautiful and we always have a choice.”

We found staff received appropriate professional development. One person living in the home said “You cannot get staff better than them".

Everyone said they would have no hesitation in making a complaint if they were unhappy. One person said “I would tell them if I was not happy.”

We visited this location on a weekday and were able to talk to five people who used the service. We were told that the staff were ‘good to us’ and they were ‘missed when they are off’; that people were ‘spoken to well’ and that the home was ‘lovely’. We were also told that all staff were ‘respectful and good’, and the food was ‘lovely’ and there was a ‘good choice’.

People who used the service said they did not have concerns and they confirmed they knew how to discuss issues and with whom.

This inspection took place on 30 November and 3 December 2015 and was unannounced. This meant the staff and provider did not know we would be visiting.

Bishopgate Lodge Care Home provides care and accommodation for up to 46 people with personal and nursing care needs. On the day of our inspection there were 46 people using the service.

The home had a registered manager in place. 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.

Bishopgate Lodge Care Home was last inspected by CQC on 30 September 2013 and was compliant.

There were sufficient numbers of staff on duty in order to meet the needs of people who used the service. The provider had an effective recruitment and selection procedure in place and carried out relevant checks when they employed staff.

Thorough investigations had been carried out in response to accidents and incidents.

People were protected against the risks associated with the unsafe use and management of medicines however some records were inconsistent.

Staff training was up to date and staff received regular supervisions. Some appraisals were overdue but were planned.

The home was clean, spacious and suitable for the people who used the service.

People were protected from the risk of poor nutrition however some food and fluid charts were not consistently recorded.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS).

We checked whether the service was working within the principles of the MCA and whether any conditions on authorisations to deprive a person of their liberty were being met. The provider was working within the principles of the MCA.

All of the care records we looked at contained evidence of consent being obtained from people or family members.

People who used the service, and family members, were complimentary about the standard of care at Bishopgate Lodge Care Home.

Staff treated people with dignity and respect and helped to maintain people’s independence by encouraging them to care for themselves where possible.

We saw that the home had a full programme of activities in place for people who used the service.

Care records showed that people’s needs were assessed before they moved into Bishopgate Lodge Care Home and care plans were written in a person centred way.

The provider had a complaints policy and procedure in place and complaints were fully investigated.

The provider had a robust quality assurance system in place and gathered information about the quality of their service from a variety of sources.

The service had good links with the local community.