Bishops Corner

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe – this means we looked for evidence that people were protected from abuse and avoidable harm. At our last assessment we rated this key question Good. At this assessment the rating has remained Good. This meant people were safe and protected from avoidable harm.

This service scored 63 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Whilst the provider had a proactive and positive culture of safety based on openness and honesty, the documentation did not always support this. Therefore, we were not fully assured that lessons were learnt to continually identify and embed good practice.

Whilst staff reported safety events and these were investigated, the outcomes with actions were not always clearly documented with a plan of action to mitigate risk and prevent a recurrence. This meant learning and risk‑reduction opportunities were missed.

For example, there had been several incidents reported between 2 people whilst in a vehicle, the only action recorded was that one person had been asked to leave the vehicle. There were no further actions recorded; however, staff told us of actions they had taken and what lessons had been learnt. Another example was a person had had an unwitnessed fall in their bedroom. Again, it was reported but the investigation into the possible cause of fall was minimal and there had been no review of environmental risk assessments to ensure the bedroom was safe from trip hazards. This has now been actioned.

The provider worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

People’s move into the service was planned and focussed on what best suited the person themselves and their families.

When people moved or were admitted to hospital, staff worked with other managers and professionals to ensure smooth transitions and that all necessary paperwork was up to date. The computer system produced a condensed care plan which contained key information about people, this was used when a person had to go to hospital. The front page of the document however needs to be updated regularly to ensure all information remains current. During hospital visits and overnight stays, staff from the service would accompany people and remain with them throughout their visit, including overnight. A senior staff member told us, “If someone needs to go to hospital, and family can’t go, we send their key worker with them to reduce anxiety and help settle them.” A health professional said, “We have no concerns about the support given by staff when they have gone to hospital for appointments and stays.”

The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The provider shared concerns quickly and appropriately.

People lived safely at the service, supported by a staff team who knew them very well and knew how best to avoid any harm. Staff were also aware and confident and reported when things went wrong. Relatives told us they felt their loved ones were safe and happy at the service. Comments included, “I know they are safe, really made improvements since they have lived there, they seem happy, content and have a good life” and “Very caring and kind.”

Safeguarding and whistleblowing policies were in place and were regularly reviewed. Staff had received training in safeguarding and were able to tell us of situations that would amount to an issue that needed reporting. We observed safe practice when staff were supporting people. Staff attended to their needs in a safe way, safeguarding them against injury and promoting their well-being.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making decisions on behalf of people who may lack the mental capacity to do so for themselves. The MCA 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 make 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. In care homes, and some hospitals, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS).

Where people needed to be deprived of their liberty to keep them safe, the provider ensured a Deprivation of Liberty Safeguard (DoLS) was applied for through the relevant local authority. Any conditions related to DoLS authorisations were being met. However, the documentation to assess people’s capacity was not always completed in full and lacked evidence of what least restrictive options had been explored and exhausted. This has been fully discussed, and all documentation will be reviewed as a priority. During the assessment process the registered manager sent some peoples’ documentation that had been reviewed and rewritten. This were completed in full and supported by evidence to underpin the decision making, therefore, any potential risk was now mitigated.

Whilst the provider worked with people to understand and manage risks by thinking holistically, this had not been reflected in peoples individual care plans and risk assessments. Despite the shortfalls found and discussed, due to staff knowledge, staff at this time provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Each person had up to date individual care plans and risk assessments. The care plans and risk assessments were all computerised and contained information about care and support needs, and associated risks, Staff entered daily notes on hand-held devices, these provided information about people’s risks and mitigation strategies for staff to provide safe and effective care, but as discussed were very generic and not person specific. This was acknowledged by the registered manager who was responsive to this feedback and started work immediately to rectify this.

Staff were knowledgeable about the people they supported, and the risks associated with their care. This included managing nutritional risks for those who lived with Prader Willi syndrome and diabetes. There were some related health conditions that had not been reflected in peoples care plans, for example, One person lived with Raynaud’s disease and others with leg oedema.

Risk assessments supported staff to manage identified risks whilst ensuring people's rights and independence was promoted and respected. Positive risk taking was supported and encouraged in line with the principles of Registering the Right support, Right care, Right culture to support people with managing their nutritional risks whilst promoting independence and enjoying going out in the community. There was positive feedback from people and families about how staff supported them to manage mealtimes and temptation. Most of the people spoken with were very aware of their diagnosis, and of the reasons for restrictions and how to stay safe. This needs to be reflected into the care plans. The registered manager had identified on the recent audit that people and families voice was missing from care plans and risk management and had included this on the service improvement plan.

There were arrangements in place to deal with foreseeable emergencies and to maintain the safety of the premises. People had individual emergency evacuation plans (PEEP) in place which highlighted the level of support they required to evacuate the building safely in the event of an emergency. The PEEPs were currently being reviewed to ensure they were all current.

The provider detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. There were regular safety checks being completed by qualified external contractors. People and their relatives told us they had access to the equipment they needed to stay safe.

There was a system to ensure the home and equipment was maintained and serviced. There were regular servicing contracts which included electrical safety and fire risk assessment. Where improvements were identified plans were in place to address these and make the necessary improvements. Health and safety checks had been undertaken to ensure safe management of utilities, food hygiene, hazardous substances, and moving and handling equipment. this included fire and water temperature checks. Premises risk assessments and health and safety assessments were reviewed on an annual basis.

Staff received fire safety training and fire drills were undertaken to ensure staff knew what actions to take in an emergency. There were regular checks of equipment for example, door alarms to ensure people were kept safe.

The provider made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

We observed interactions between people and staff; people appeared to be in control of their day and were relaxed in the company of staff. Staff were knowledgeable and showed a good understanding of people they supported. Staff had undertaken training in how to support people who lived with PWS, autism, and how to support people with a learning disability. Staff skills and competency were regularly assessed. Staff told us, “I've had training for learning disability, moving and handling, food hygiene and autism.”

New staff went through a thorough induction process and were supported with regular supervision meetings, spot and competency checks. Staff were fully trained in essential training, such as fire safety, food hygiene and infection control. The provider told us that all staff would have training in diabetes as 2 people in the service lived with diabetes. The registered provider was to check on the organisational training for medicines, and the frequency of medicine competency checks as some had not been undertaken since 2021.

Staff were recruited safely. The provider undertook checks on new staff before they started work. This included checking their identity, their eligibility to work in the UK, obtaining at least 2 references from previous employers and Disclosure and Barring Service (DBS) checks. The DBS helps employers make safer recruitment decisions and prevent unsuitable people from working with vulnerable people.

The provider did not always assess or manage the risk of infection. The overall cleanliness of the service needed attention, mainly in staff areas, such as medicine storage room and communal areas. This was acknowledged and immediate action taken. The care staff were responsible for cleaning the service, this was additional to their role of supporting people, and this will be reviewed going forward.

People were supported by staff in cleaning their rooms and doing their laundry, and they did this on their specific allocated day.

Staff had all received training in infection prevention and control (IPC) and there was a large supply of personal protective equipment (PPE) which was used appropriately by staff.

Infection Protection Control and PPE policies were in place and were reviewed each time government guidelines were updated.

The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Staff did not always involve people in planning.

There were some areas of the management of medicines that were in need of updating to ensure all the information was correct.

The registered manager immediately took action and updated peoples’ documentation and photographs. We were told peoples profiles on the care plan was up to date but not printed off.

Protocols for 'as required' (PRN) medicines such as pain relief medicines were in place, however, they lacked individual personalisation and were not robustly linked to a pain care plan or pain tool. On discussion with staff, they were able to discuss how people showed they were in pain or discomfort, but this was not easily found within people’s documentation. This was fully acknowledged by the management team and was being addressed. The current management of homely medicines needed to be more robust, and evidence provided of discussion with the GP and pharmacist. We saw this was actioned immediately.

The staff worked closely with the GP and the Medicines Optimisation in Care Homes team, (which is a program by NHS England, which focuses on improving medication management for residents) to ensure medicines were reviewed regularly. The staff were aware of the protocols about Stopping Over Medication of People with a learning disability, autism or both (STOMP).

Care plans include information about medication but does not provide guidance as to reasons for being prescribed the medication and potential side effects that could impact health. For example, people prescribed psychotropics but there was no reason why recorded, or if they had ever been reviewed or were still required. This was fully discussed with the RM who immediately initiated medication reviews for all people