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Inspection Summary


Overall summary & rating

Good

Updated 13 October 2017

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

This comprehensive inspection was undertaken on 4 September 2017 and was unannounced.

At the inspection in January 2017 a number of breaches were identified and the service was rated requires improvement. The Care Quality Commission (CQC) took enforcement action and issued a Warning Notice after the inspection as the provider had not ensured good governance. We also found four further breaches in relation to person centred care, dignity and respect, safe care and treatment, and meeting nutritional needs. This inspection took place on 4 September 2017 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. The provider was now meeting the regulations.

There was no registered manager at Bishops Corner. 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.’

A new acting manager had begun working at Bishops Corner and was starting the process of registering as manager with CQC. Staff told us the current acting manager had made positive changes and impact during their time at Bishops Corner. The acting manager had previously worked at a number of services owned by the organisation so they knew staff and people living at Bishops Corner well. The acting manager was going to be registering as manager over three services owned by the provider. A clear structure was in the process of being implemented to provide consistent management cover. The acting manager had a timetable to ensure staff knew where they were and to enable them to provider management support at each of the three services. However, there needed to be a clear structure to support them with this and to make sure this was consistently maintained. At the time of the inspection some of the support roles had not yet been fully recruited. Therefore this is something that will need to be monitored to ensure continued improvement.

The provider had safe recruitment processes and appropriate checks took place before people began work at Bishops Corner. New staff completed a period of induction and all staff received training including safeguarding and PWS specific training to ensure they were able to meet the needs of people living at Bishops Corner. Supervision was taking place to support staff, as well as staff, resident and relative meetings and questionnaires to improve communication. There were enough staff to meet people's needs.

People’s confidentiality was maintained and records were kept securely. People received care which was assessed, planned and reviewed to ensure their needs were met and to reflect their preferences. Support plans included advice about people’s nutrition, medicines and support needs. Staff had access to relevant information about people; this meant they knew people and their care needs well. Staff communicated with people in a caring and supportive manner. Staff knew people well and people were treated with respect and dignity. People’s nutrition was monitored and reviewed based on their individual needs. Changes were introduced slowly to ensure this did not cause undue anxiety for people.

People were involved in decisions and choices when it was appropriate. Mental Capacity Act 2005 (MCA) assessments were completed as required and in line with legal requirements. Staff had attended MCA and Deprivation of Liberty Safeguards (DoLS) training.

People told us they enjoyed the activities provided and people were supported and

Inspection areas

Safe

Good

Updated 13 October 2017

Bishops Corner was safe and was meeting the legal requirements that were previously in breach.

Individual and environmental risk assessments were in place when risks to people�s safety had been identified. A structured system was in place for responding to and recording accidents and incidents and peoples medicines were managed safely.

There were protocols for people who required one to one support. Staff had an understanding of recognising and reporting abuse.

The provider had safe recruitment processes; appropriate checks took place before people began work at Bishops Corner and there were enough staff to meet people's needs.

There was on-going maintenance and servicing of equipment. Fire safety checks had taken place.

Effective

Good

Updated 13 October 2017

Bishops Corner was effective and was meeting the legal requirements that were previously in breach.

People�s nutrition was monitored and reviewed based on people�s individual needs. Changes were introduced slowly to ensure this did not cause undue anxiety for people.

People were supported to attend health appointments and referrals were made to other health professionals if needed.

Staff induction, training and supervision programmes were taking place.

Mental Capacity Act 2005 (MCA) assessments were completed as required and in line with legal requirements. Staff had attended MCA and Deprivation of Liberty Safeguards (DoLS) training.

Caring

Good

Updated 13 October 2017

Bishops Corner was caring and was meeting the legal requirements that were previously in breach.

Improvements had been made to ensure people�s dignity and privacy were maintained at all times.

Staff communicated with people in a caring and supportive manner. Staff knew people well and people were treated with respect and dignity.

People were supported to maintain relationships which were important to them.

People�s confidentiality was maintained and records were kept securely.

Responsive

Good

Updated 13 October 2017

Bishops Corner was responsive and was meeting the legal requirements that were previously in breach.

People received care which was assessed, planned and reviewed to ensure their needs were met and to reflect their preferences.

Staff had access to relevant information about people; this meant they knew people and their care needs well.

There was a varied activity schedule. People spent time doing the things they wanted to do.

There was a complaints policy and procedure. People told us they would raise concerns if needed.

Well-led

Requires improvement

Updated 13 October 2017

Bishops Corner demonstrated on-going improvements in well-led.

The management structure at Bishops Corner was not yet fully established. The acting manager was in post but not yet registered as manager with CQC.

Support systems were in the process of being implemented to ensure consistent leadership was maintained.

People spoke positively of the improvements which had taken place. Staff felt supported and people�s views had been sought and responded to.

Notifications had been made to external organisations when required.