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Archived: Bishop's Court Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 5 November 2015

This unannounced, comprehensive inspection took place on 28 May 2015 and was conducted following receipt of information of concern. The service was registered to provide accommodation for 41 people, there were 23 people living in Bishops Court at the time.

The service is located in a single storey building and provides nursing and personal care, predominantly for people living with dementia. It is situated in the Sefton Park area of Liverpool and is close to local amenities, such as shops and local transport links to Liverpool city centre. There is a large car park at the front of Bishop's Court and the building has gardens which are fully accessible to people using the service and their visitors.

The home was registered to provide accommodation and care to people who may have nursing needs and a registered manager was employed.

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. At the time of the inspection the manager had been away from the service since 23 April 2015. A senior manager from the organisation had been managing the service since 24 April 2015 but has not submitted an application to the CQC to become the registered manager. People spoke positively about her saying she was ’’really approachable.’’

We found that there was little signage around the service to identify different areas such as toilets and dining rooms. In order to support people living with dementia we have made a recommendation in relation to this.

We found that there were sufficient numbers of staff on duty in the daytime but some staff had expressed concerns about staffing levels at night.

Medicines overall were managed safely but some improvements were required. This was because for some people there was not sufficient information recorded around the administration and review of medicines to be given when required (PRN) and a care plan was not always in place to support this. We also saw that discontinued medications were not always supported by a signature from a nurse or G.P. The service provided information at a later date to show that they had sufficient safeguards to ensure that discontinued medication was verified by an appropriate professional.

People living in Bishops Court, staff, relatives and professionals that we spoke with were all positive about the service provided. The people living at the home and relatives told us they felt safe.

We saw there were effective recruitment procedures in place and staff performance issues were addressed appropriately.

The staff in the home knew the people they were supporting and the care they needed. The staff were trained and competent to provide the support required by the individuals.

There was a calm, relaxed atmosphere within the home and we observed good interaction between people living at Bishops Court, staff and visitors.

The care plans that we reviewed showed that preadmission assessments had been conducted and consent forms to care plans had been completed and signed by either the people using the service or their representatives. This showed that people using the service and their representatives had been involved in their care planning. There was adequate information available in the care plans to ensure people using the service to be supported in an individualised way that met their needs.

There was a complaints policy available, and there was evidence that complaints were dealt with effectively.

Inspection areas

Safe

Requires improvement

Updated 5 November 2015

The service was not always safe.

We found the building was well maintained.

Staff were recruited safely and trained to meet the needs of people who lived in the home and knew how to recognise and report abuse.

Effective

Requires improvement

Updated 5 November 2015

The service was not always effective.

We found that the environment would benefit from improved design and orientation signs to support people with dementia.

The staff in the home knew the people they were supporting and the care they needed. The staff were trained and competent to provide the support

Individuals required

Caring

Good

Updated 5 November 2015

The service was caring.

We found a calm, relaxed atmosphere within the home and saw that there was a good interaction between staff and people using the service.

There were no visiting restrictions at the service. When asked, staff were able to explain the individual needs of people they were supporting and staff also supported each other.

Responsive

Good

Updated 5 November 2015

Pre- admission assessments had been conducted which helped ensure the provider could meet the individual person`s needs.

There was a complaints procedure and staff were able to identify the individual needs of the people they were supporting and put them in to practice in a person centred way.

Well-led

Requires improvement

Updated 5 November 2015

The service was well-led.

The service did not have a manager registered with CQC.

The manager was away from the service at the time of the inspection but appropriate arrangements were in place during this time.

We saw that relevant audits and equipment checks had been conducted and the provider had systems and processes in place to support this.